Provider Demographics
NPI:1730127804
Name:VANBODEGOM, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:VANBODEGOM
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:PO BOX 34936
Mailing Address - Street 2:DEPT # 5006
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1936
Mailing Address - Country:US
Mailing Address - Phone:206-439-2988
Mailing Address - Fax:206-431-3939
Practice Address - Street 1:16110 8TH AVE SW
Practice Address - Street 2:SUITE A2
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-2962
Practice Address - Country:US
Practice Address - Phone:206-242-8280
Practice Address - Fax:206-242-8302
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00012580207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA05846Medicare UPIN