Provider Demographics
NPI:1326122268
Name:DOLACK, GEORGE L (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:L
Last Name:DOLACK
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:PO BOX 59028
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-2028
Mailing Address - Country:US
Mailing Address - Phone:425-251-5110
Mailing Address - Fax:425-793-7458
Practice Address - Street 1:4011 TALBOT ROAD SOUTH
Practice Address - Street 2:SUITE 500
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055
Practice Address - Country:US
Practice Address - Phone:425-251-5110
Practice Address - Fax:425-793-7376
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023180207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA110138451OtherRR MEDICARE
WA0111626OtherL&I
WA8107757Medicaid
WAG000107101Medicare PIN
WA110138451OtherRR MEDICARE