Provider Demographics
NPI:1023090180
Name:BERTOZZI, PETER E JR (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:E
Last Name:BERTOZZI
Suffix:JR
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 34245
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1245
Mailing Address - Country:US
Mailing Address - Phone:206-622-7747
Mailing Address - Fax:206-467-1470
Practice Address - Street 1:1001 KLICKITAT WAY SW
Practice Address - Street 2:#205
Practice Address - City:SEATLE
Practice Address - State:WA
Practice Address - Zip Code:98134
Practice Address - Country:US
Practice Address - Phone:206-622-7747
Practice Address - Fax:206-467-1470
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014440207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8481905Medicaid
WA125694OtherST LABOR AND INDUSTRIES
WA8481905Medicaid
A08886Medicare UPIN