1528093861 NPI number — DR. JOHN LAWRENCE HEADLEY M.D.

Table of content: DR. JOHN LAWRENCE HEADLEY M.D. (NPI 1528093861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528093861 NPI number — DR. JOHN LAWRENCE HEADLEY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEADLEY
Provider First Name:
JOHN
Provider Middle Name:
LAWRENCE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1528093861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21600 HIGHWAY 99
Provider Second Line Business Mailing Address:
#280
Provider Business Mailing Address City Name:
EDMONDS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98026-8012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-774-2616
Provider Business Mailing Address Fax Number:
425-774-2660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21600 HIGHWAY 99
Provider Second Line Business Practice Location Address:
#280
Provider Business Practice Location Address City Name:
EDMONDS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98026-8012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-774-2616
Provider Business Practice Location Address Fax Number:
425-774-2660
Provider Enumeration Date:
07/12/2006

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: 207ND0101X , with the licence number:  MD00018010 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1030683 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com