1437370111 NPI number — DR. JACQUELINE VASEN RIDDICK M.D.

Table of content: DR. JACQUELINE VASEN RIDDICK M.D. (NPI 1437370111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437370111 NPI number — DR. JACQUELINE VASEN RIDDICK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIDDICK
Provider First Name:
JACQUELINE
Provider Middle Name:
VASEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VASEN
Provider Other First Name:
JACQUELINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1437370111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1511 6TH AVE STE 360
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98101-1759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-470-1860
Provider Business Mailing Address Fax Number:
206-834-9591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 UNIVERSITY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98101-2772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-470-1860
Provider Business Practice Location Address Fax Number:
206-834-9591
Provider Enumeration Date:
05/01/2007

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: 207Q00000X , with the licence number:  MD 60041895 , 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: 8563348 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".