Healthcare Provider Details

I. General information

NPI: 1265414460
Provider Name (Legal Business Name): MARK A UNDERWOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W 8TH AVE
SPOKANE WA
99204-2307
US

IV. Provider business mailing address

15915 W SILVER LAKE RD
MEDICAL LAKE WA
99022-9599
US

V. Phone/Fax

Practice location:
  • Phone: 509-474-3131
  • Fax:
Mailing address:
  • Phone: 530-867-6234
  • Fax: 916-456-4490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD61106174
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberA45353
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: