Provider Demographics
NPI:1760490692
Name:DEJONG VANCOEVORDEN, REINIER (MD)
Entity Type:Individual
Prefix:DR
First Name:REINIER
Middle Name:
Last Name:DEJONG VANCOEVORDEN
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 1:1420 NW GILMAN BLVD.
Mailing Address - Street 2:PMB 2856
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:87027
Mailing Address - Country:US
Mailing Address - Phone:425-557-4227
Mailing Address - Fax:425-557-2858
Practice Address - Street 1:1301 4TH AVE NW STE 204
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-9371
Practice Address - Country:US
Practice Address - Phone:425-557-4227
Practice Address - Fax:425-557-2858
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAF35569Medicare UPIN