Provider Demographics
NPI:1619052438
Name:REILLY, DOMINIC FRANCIS
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:FRANCIS
Last Name:REILLY
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:UNIVERSITY OF WASHINGTON MEDICAL CTR
Practice Address - Street 2:1959 NE PACIFIC ST
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-6127
Practice Address - Country:US
Practice Address - Phone:206-598-5160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027876207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1619052438Medicaid
WA0231951OtherL&I
WA110064469OtherRAIL ROAD MEDICARE
9492OtherINTERNAL ID-MOTOR VEHICLE ID
WA1619052438Medicaid
WAAB27234Medicare PIN
WA000107610Medicare PIN