Provider Demographics
NPI:1134109242
Name:ETZKORN, EUGENE THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:THOMAS
Last Name:ETZKORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7622 98TH AVENUE CT SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-3269
Mailing Address - Country:US
Mailing Address - Phone:253-588-0379
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CTR
Practice Address - Street 2:9040 A REID ST.
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-1110
Practice Address - Fax:253-968-1188
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034340207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB1747Medicare ID - Type Unspecified
WAG45294Medicare UPIN