Basic Information
| Provider Information | |||||||||
| NPI: | 1730127804 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANBODEGOM | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34936 | ||||||||
| Address2: | DEPT # 5006 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064392988 | ||||||||
| FaxNumber: | 2064313939 | ||||||||
| Practice Location | |||||||||
| Address1: | 16110 8TH AVE SW | ||||||||
| Address2: | SUITE A2 | ||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981662962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062428280 | ||||||||
| FaxNumber: | 2062428302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00012580 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.