Provider Demographics
NPI:1700864261
Name:OVERBECK, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:OVERBECK
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 1:4803 55TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-1518
Mailing Address - Country:US
Mailing Address - Phone:206-579-8871
Mailing Address - Fax:
Practice Address - Street 1:4803 55TH AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-1518
Practice Address - Country:US
Practice Address - Phone:206-579-8871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035253207UN0901X, 208D00000X, 207UN0902X
PAMD4553862085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA130268OtherL&I PROVIDER NUMBER
WA175496OtherL&I PROVIDER NUMBER
WA8234643Medicaid
WA8234643Medicaid
WAAB06593Medicare ID - Type UnspecifiedPROVIDER NUMBER
WAAB39938Medicare ID - Type UnspecifiedPROVIDER NUMBER
WA8234643Medicaid