Provider Demographics
NPI:1043390982
Name:DYDELL, JEAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:R
Last Name:DYDELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12303 NE 130TH LN STE 450
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3032
Mailing Address - Country:US
Mailing Address - Phone:425-899-5000
Mailing Address - Fax:425-899-5006
Practice Address - Street 1:12303 NE 130TH LN STE 450
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3032
Practice Address - Country:US
Practice Address - Phone:425-899-5000
Practice Address - Fax:425-899-5006
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038545207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1114297Medicaid
WAG02203Medicare UPIN
WAAB25821Medicare ID - Type UnspecifiedMEDICARE NUMBER