Provider Demographics
NPI:1861493272
Name:EASTSIDE ENDOCRINOLOGY AND DIABETES, PS
Entity Type:Organization
Organization Name:EASTSIDE ENDOCRINOLOGY AND DIABETES, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:WALLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-453-9762
Mailing Address - Street 1:2020 116TH AVE NE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3059
Mailing Address - Country:US
Mailing Address - Phone:425-453-9762
Mailing Address - Fax:425-455-5953
Practice Address - Street 1:2020 116TH AVE NE
Practice Address - Street 2:SUITE 150
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3059
Practice Address - Country:US
Practice Address - Phone:425-453-9762
Practice Address - Fax:425-455-5953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024156207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1022656Medicaid
WA1022656Medicaid
A14887Medicare UPIN