Provider Demographics
NPI:1730112285
Name:OVERLAKE NEUROLOGY
Entity Type:Organization
Organization Name:OVERLAKE NEUROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:FOSMIRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-709-7055
Mailing Address - Street 1:PO BOX 94568
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-6868
Mailing Address - Country:US
Mailing Address - Phone:888-846-5527
Mailing Address - Fax:607-324-2369
Practice Address - Street 1:1135 116TH AVE NE
Practice Address - Street 2:SUITE 200
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4623
Practice Address - Country:US
Practice Address - Phone:425-709-7055
Practice Address - Fax:425-709-7066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602-380-6992084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA182686OtherL & I WORKERS COMP GRP #
WA7124977Medicaid
WA182686OtherL & I WORKERS COMP GRP #
WADC0528Medicare PIN