Provider Demographics
NPI:1164580767
Name:DUNDORE, DIANA E (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:E
Last Name:DUNDORE
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 1:2500 LAKE PARK DR S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-5609
Mailing Address - Country:US
Mailing Address - Phone:206-725-8557
Mailing Address - Fax:
Practice Address - Street 1:2500 LAKE PARK DR S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-5609
Practice Address - Country:US
Practice Address - Phone:206-725-8557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA252-09 0015045208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA18390OtherLABOR AND INDUSTRIES
WA1923804Medicaid
WA2D896Medicare ID - Type Unspecified
WA1923804Medicaid