1225195431 NPI number — STEPHAN CASSIDY OD PS

Table of content: BENEDICT COLEMAN DEL BUONO MD (NPI 1114542578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225195431 NPI number — STEPHAN CASSIDY OD PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHAN CASSIDY OD PS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1225195431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
450 NW GILMAN BLVD
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
ISSAQUAH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98027-2483
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-392-8756
Provider Business Mailing Address Fax Number:
425-391-8631

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 NW GILMAN BLVD
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
ISSAQUAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98027-2483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-392-8756
Provider Business Practice Location Address Fax Number:
425-391-8631
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CASSIDY
Authorized Official First Name:
STEPHAN
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
425-392-8756

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2081305 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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