Healthcare Provider Details

I. General information

NPI: 1710041793
Provider Name (Legal Business Name): MARK D KIVIAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 17TH AVE STEA10C
SEATTLE WA
98122-5711
US

IV. Provider business mailing address

PO BOX 84026
SEATTLE WA
98124-8426
US

V. Phone/Fax

Practice location:
  • Phone: 206-860-6656
  • Fax: 206-320-3396
Mailing address:
  • Phone: 206-860-6656
  • Fax: 206-320-3396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD00010647
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: