Healthcare Provider Details

I. General information

NPI: 1760424816
Provider Name (Legal Business Name): GWEN MARCUS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9635 17TH AVE SW
SEATTLE WA
98106-2712
US

IV. Provider business mailing address

PO BOX 34936 DEPT # 5006
SEATTLE WA
98124-1936
US

V. Phone/Fax

Practice location:
  • Phone: 206-763-5057
  • Fax: 206-763-5241
Mailing address:
  • Phone: 206-439-2988
  • Fax: 206-431-3939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD00038714
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: