Provider Demographics
NPI:1629241112
Name:OVERLAKE FAMILY VISION, PLLC
Entity Type:Organization
Organization Name:OVERLAKE FAMILY VISION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-638-0700
Mailing Address - Street 1:1135 116TH AVE NE STE120
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4626
Mailing Address - Country:US
Mailing Address - Phone:425-638-0700
Mailing Address - Fax:
Practice Address - Street 1:1135 116TH AVE NE STE120
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4626
Practice Address - Country:US
Practice Address - Phone:425-638-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2010-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1995TX305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8871145Medicare PIN