Provider Demographics
NPI:1164532941
Name:HARLOCK, DENIS A (MD)
Entity Type:Individual
Prefix:
First Name:DENIS
Middle Name:A
Last Name:HARLOCK
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 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-855-1411
Mailing Address - Fax:360-855-1933
Practice Address - Street 1:830 BALL ST
Practice Address - Street 2:
Practice Address - City:SEDRO-WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-0450
Practice Address - Country:US
Practice Address - Phone:360-855-1411
Practice Address - Fax:360-855-1411
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8333734Medicaid
WA8333734Medicaid
G26733Medicare UPIN