1609292002 NPI number — DR. BENJAMIN WALTER DONALD ILES DO

Table of content: DR. BENJAMIN WALTER DONALD ILES DO (NPI 1609292002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609292002 NPI number — DR. BENJAMIN WALTER DONALD ILES DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ILES
Provider First Name:
BENJAMIN
Provider Middle Name:
WALTER DONALD
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:
1609292002
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19020 33RD AVE W STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNNWOOD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98036-4748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-563-1500
Provider Business Mailing Address Fax Number:
425-563-1374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 17TH AVE
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:
98122-5711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-320-3700
Provider Business Practice Location Address Fax Number:
206-320-5955
Provider Enumeration Date:
03/10/2014

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: 2085P0229X , with the licence number:  OP61040926 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: OP61040926 , 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: 0427472 . This is a "L&I-SWEDISH RADIA EDMONDS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0427478 . This is a "L&I-VANCOUVER RADIOLOGY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0427470 . This is a "L&I-RADIA REST OF WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0427471 . This is a "L&I-RADIA KING CTY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0427473 . This is a "L&I-EVERGREEN RADIA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0427475 . This is a "L&I-SOUTH SOUND" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0427477 . This is a "L&I-SEATTLE RADIOLOGY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2155919 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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