Provider Demographics
NPI:1174664130
Name:HAUTALA, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:HAUTALA
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 1:1033 REGENTS BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6045
Mailing Address - Country:US
Mailing Address - Phone:253-564-1115
Mailing Address - Fax:253-565-4552
Practice Address - Street 1:1033 REGENTS BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6045
Practice Address - Country:US
Practice Address - Phone:253-564-1115
Practice Address - Fax:253-565-4552
Is Sole Proprietor?:No
Enumeration Date:2007-02-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000190592080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1783703Medicaid
WAMD00019059OtherSTATE LICENSE NUMBER
WA108917OtherL&I NUMBER
WAHA7840OtherREGENCE BLUE SHIELD
WAAH1062239OtherDEA NUMBER
WAE57821Medicare UPIN
WA1783703Medicaid