1336198563 NPI number — DR. MICHAEL T ONTKEAN DO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336198563 NPI number — DR. MICHAEL T ONTKEAN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ONTKEAN
Provider First Name:
MICHAEL
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336198563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 NE MOTHER JOSEPH PL
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98664-3299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-514-4444
Provider Business Mailing Address Fax Number:
360-514-6530

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 NE MOTHER JOSEPH PL
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98664-3299
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-256-2640
Provider Business Practice Location Address Fax Number:
360-260-7288
Provider Enumeration Date:
05/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  OP00001374 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0011X , with the licence number: OP00001374 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8109654 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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