Provider Demographics
NPI:1164491403
Name:LOVE, TOMMY L (DO)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:L
Last Name:LOVE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11400 SE 8TH ST
Mailing Address - Street 2:STE 210
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-6461
Mailing Address - Country:US
Mailing Address - Phone:425-688-3730
Mailing Address - Fax:425-453-6345
Practice Address - Street 1:1740 NW MAPLE ST
Practice Address - Street 2:STE 100
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-8924
Practice Address - Country:US
Practice Address - Phone:425-313-4800
Practice Address - Fax:425-391-1689
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT4551473-1204207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD3487Medicaid
WA1164491403Medicaid
UT005566502Medicare ID - Type Unspecified
WAG8897201Medicare PIN
UTD3487Medicaid