Provider Demographics
NPI:1598075764
Name:WERNER, MIKE DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:DAVID
Last Name:WERNER
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 1:5424 HEIGHTS LN NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-1872
Mailing Address - Country:US
Mailing Address - Phone:360-753-1372
Mailing Address - Fax:
Practice Address - Street 1:3432 S BAY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-2958
Practice Address - Country:US
Practice Address - Phone:360-493-4688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00041419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD 00041419OtherWA STATE DEPARTMENT OF HEALTH PHYSICIAN LICENSE