Provider Demographics
NPI:1407199540
Name:CHAMPLIN, JAY ELLWORTH (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:ELLWORTH
Last Name:CHAMPLIN
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:UW RADIOLOGY DEPT RR 210
Mailing Address - Street 2:1959 N.E. PACIFIC STREET, BOX 357115
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-7115
Mailing Address - Country:US
Mailing Address - Phone:206-598-6483
Mailing Address - Fax:
Practice Address - Street 1:5230 CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15232-1304
Practice Address - Country:US
Practice Address - Phone:412-623-2465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2019-05242085R0204X, 2085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program