1669551008 NPI number — GREGORY R JESPERSEN DPM

Table of content: GREGORY R JESPERSEN DPM (NPI 1669551008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669551008 NPI number — GREGORY R JESPERSEN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JESPERSEN
Provider First Name:
GREGORY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1669551008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1786
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUVALL
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98019-1786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-788-1484
Provider Business Mailing Address Fax Number:
425-788-2024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19309 218TH PL NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODINVILLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98077-7112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-788-1484
Provider Business Practice Location Address Fax Number:
425-788-2024
Provider Enumeration Date:
11/05/2006

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: 213E00000X , with the licence number:  PO00000415 , 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: 213E00000X , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".