Provider Demographics
NPI:1275669459
Name:OLDENKAMP, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:OLDENKAMP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12811 8TH AVE W
Mailing Address - Street 2:SUITE D-109
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-6335
Mailing Address - Country:US
Mailing Address - Phone:425-743-7888
Mailing Address - Fax:425-355-3055
Practice Address - Street 1:12811 8TH AVE W
Practice Address - Street 2:SUITE D-109
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-6335
Practice Address - Country:US
Practice Address - Phone:425-743-7888
Practice Address - Fax:425-355-3055
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023394207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-1504734OtherTAX ID
WA1011832Medicaid
WA91-1504734OtherTAX ID
WA1011832Medicaid