Provider Demographics
NPI:1346326121
Name:DREZNER, JONATHAN ADAM
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ADAM
Last Name:DREZNER
Suffix:
Gender:M
Credentials:
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 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:UWMC-ROOSEVELT
Practice Address - Street 2:4245 ROOSEVELT WAY NE
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4770
Practice Address - Country:US
Practice Address - Phone:206-598-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036878207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000323OtherINTERNAL ID-MOTOR VEHICLE ID
WA080161897OtherRAIL ROAD MEDICARE
WA8247389Medicaid
WA080161897OtherRAIL ROAD MEDICARE
2000323OtherINTERNAL ID-MOTOR VEHICLE ID
WA8804979Medicare PIN