Healthcare Provider Details

I. General information

NPI: 1487651667
Provider Name (Legal Business Name): MARK LUTHER SCHLAUDERAFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 PROFESSIONAL WAY
SHELTON WA
98584-4404
US

IV. Provider business mailing address

237 PROFESSIONAL WAY
SHELTON WA
98584-4404
US

V. Phone/Fax

Practice location:
  • Phone: 360-426-2500
  • Fax: 360-462-2500
Mailing address:
  • Phone: 360-426-2500
  • Fax: 360-462-2500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00019248
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: