Basic Information
| Provider Information | |||||||||
| NPI: | 1174780530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIDGELEY | ||||||||
| FirstName: | JAMISON | ||||||||
| MiddleName: | RODGER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 MADISON ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062152020 | ||||||||
| FaxNumber: | 2062152055 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 MADISON ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062152020 | ||||||||
| FaxNumber: | 2062152055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2008 | ||||||||
| LastUpdateDate: | 04/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD60638738 | WA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1174780530 | 05 | NC | MEDICAID |