Provider Demographics
NPI:1639167638
Name:DEJONG, ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:DEJONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-339-5422
Mailing Address - Fax:425-339-5444
Practice Address - Street 1:3927 RUCKER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4833
Practice Address - Country:US
Practice Address - Phone:425-339-5422
Practice Address - Fax:425-339-5444
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14042207Q00000X
WAMD00024413207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2055678Medicaid
NV1639167638Medicaid
NVP01332614OtherRR MEDICARE
NVFL565ZMedicare PIN
NVP01332614OtherRR MEDICARE
NV1639167638Medicaid