Provider Demographics
NPI:1437799863
Name:EGER, DMITRY (LMT)
Entity Type:Individual
Prefix:
First Name:DMITRY
Middle Name:
Last Name:EGER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SW EVERETT MALL WAY STE G
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-2715
Mailing Address - Country:US
Mailing Address - Phone:425-355-5222
Mailing Address - Fax:425-355-5231
Practice Address - Street 1:606 120TH AVE NE STE 100
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-3024
Practice Address - Country:US
Practice Address - Phone:425-688-0223
Practice Address - Fax:425-688-9323
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAMA61019709225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA61019709OtherWA STATE LICENSE