Healthcare Provider Details

I. General information

NPI: 1962575951
Provider Name (Legal Business Name): MARC D PELLICCIARO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date: 05/09/2018
Reactivation Date: 05/16/2018

III. Provider practice location address

12729 NORTHUP WAY STE 6
BELLEVUE WA
98005-1935
US

IV. Provider business mailing address

12729 NORTHUP WAY STE 6
BELLEVUE WA
98005-1935
US

V. Phone/Fax

Practice location:
  • Phone: 425-467-1000
  • Fax: 425-467-0100
Mailing address:
  • Phone: 425-467-1000
  • Fax: 425-467-0100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberMD 00036813
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: