Provider Demographics
NPI:1790721736
Name:ERNST, JEFFREY CLARK (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CLARK
Last Name:ERNST
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 1:357 NW RICHMOND BEACH RD
Mailing Address - Street 2:RICHMOND PEDIATRICS
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98177
Mailing Address - Country:US
Mailing Address - Phone:206-546-2421
Mailing Address - Fax:206-542-9028
Practice Address - Street 1:357 NW RICHMOND BEACH RD
Practice Address - Street 2:RICHMOND PEDIATRICS
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98177
Practice Address - Country:US
Practice Address - Phone:206-546-2421
Practice Address - Fax:206-546-8436
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2014-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA38513208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8253270Medicaid
WA8253270Medicaid