Provider Demographics
NPI:1164490892
Name:GRADEK, WALTER QUINTON (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:QUINTON
Last Name:GRADEK
Suffix:
Gender:M
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:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1600 E JEFFERSON ST STE 600
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122
Practice Address - Country:US
Practice Address - Phone:206-861-8550
Practice Address - Fax:206-861-8551
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046107207RC0000X
WAMD60917858207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1164490892Medicaid
GA202I063061Medicare PIN
GAI50704Medicare UPIN