MEDICARE: MARK ELLESTAD MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	MD60492007	WA
2	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician	MD60492007	WA

General Provider Information

NPI Number	:	1891087136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK ELLESTAD MD

Provider Business Mailing Address
First Line	:	3417 EVANSTON AVE N STE 306
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-8967
Country	:	US
Telephone Number	:	206-659-1750
Fax Number	:	206-752-8505

Provider Business Practice Location Address
First Line	:	3417 EVANSTON AVE N STE 306
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-8967
Country	:	US
Telephone Number	:	206-251-4014
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2011
Last Update Date	:	03/24/2026

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