Provider Demographics
NPI:1366594749
Name:LIN, MARK T (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:LIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 E TANGERINE RD STE 123
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85755-6214
Mailing Address - Country:US
Mailing Address - Phone:520-901-6336
Mailing Address - Fax:
Practice Address - Street 1:1521 E TANGERINE RD STE 123
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-6214
Practice Address - Country:US
Practice Address - Phone:520-901-6336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008024820207RG0100X
AZ42987207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ511460Medicaid
AZ511460Medicaid