Provider Demographics
NPI:1437197779
Name:EGGEN, JON TODD (DO)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:TODD
Last Name:EGGEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 742997
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-2997
Mailing Address - Country:US
Mailing Address - Phone:360-514-2142
Mailing Address - Fax:360-514-6820
Practice Address - Street 1:600 NE 92ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3225
Practice Address - Country:US
Practice Address - Phone:360-514-2142
Practice Address - Fax:360-514-6820
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001410207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278164Medicaid
WA8146268Medicaid
WAG8855575Medicare PIN
WA8146268Medicaid