Provider Demographics
NPI:1629063664
Name:REA, GARY L (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:REA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3007
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98114-3007
Mailing Address - Country:US
Mailing Address - Phone:206-788-3500
Mailing Address - Fax:206-652-5216
Practice Address - Street 1:3815 S OTHELLO ST FL 2
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-3510
Practice Address - Country:US
Practice Address - Phone:206-788-3500
Practice Address - Fax:206-652-5216
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA60167344207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0616748Medicaid
OHA16289Medicare UPIN
OHRE0576328Medicare PIN