Healthcare Provider Details

I. General information

NPI: 1891087136
Provider Name (Legal Business Name): MARK ELLESTAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE
SEATTLE WA
98104-2420
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 206-520-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberMD60492007
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD60492007
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: