Provider Demographics
NPI:1871680447
Name:DEGROOT, MICHAEL ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:DEGROOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W STE 210
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4748
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000406642085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1093030Medicaid
WA1871680447Medicaid
WA0237273OtherL&I-RADIA REST OF WA
COC807707Medicare PIN
COG19207Medicare UPIN