Provider Demographics
NPI:1225131865
Name:TADLOCK, LAURI M (MD)
Entity Type:Individual
Prefix:
First Name:LAURI
Middle Name:M
Last Name:TADLOCK
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 1:14030 NE 24TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007
Mailing Address - Country:US
Mailing Address - Phone:425-454-1104
Mailing Address - Fax:425-454-1290
Practice Address - Street 1:14030 NE 24TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007
Practice Address - Country:US
Practice Address - Phone:425-454-1104
Practice Address - Fax:425-454-1290
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021891207N00000X, 207NS0135X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1087154Medicaid
TA0069OtherREGENCE
WA070007061OtherRAILROAD MEDICARE
4120050OtherAETNA
WACN9262OtherRAILROAD MEDICARE
WA7080237Medicaid
WACN9262OtherRAILROAD MEDICARE
WA217127600Medicare ID - Type Unspecified
WA070007061OtherRAILROAD MEDICARE