Provider Demographics
NPI:1275539264
Name:DOUGLASS, J KIRK (CPO)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:KIRK
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10740 MERIDIAN AVE N
Mailing Address - Street 2:STE G2
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-9010
Mailing Address - Country:US
Mailing Address - Phone:206-363-7790
Mailing Address - Fax:206-363-7688
Practice Address - Street 1:10740 MERIDIAN AVE N
Practice Address - Street 2:STE G2
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-9010
Practice Address - Country:US
Practice Address - Phone:206-363-7790
Practice Address - Fax:206-363-7688
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOI00000062222Z00000X
WAPS00000063224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8418840Medicaid