Provider Demographics
NPI:1336254051
Name:SOUTHGATE MEDICAL CLINIC, P.S.
Entity Type:Organization
Organization Name:SOUTHGATE MEDICAL CLINIC, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:A
Authorized Official - Last Name:VELASCO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:206-723-9853
Mailing Address - Street 1:6044 MARTIN LUTHER KING JR WAY S STE 104
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-3179
Mailing Address - Country:US
Mailing Address - Phone:206-723-9853
Mailing Address - Fax:206-723-0849
Practice Address - Street 1:6044 MARTIN LUTHER KING JR WAY S STE 104
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-3179
Practice Address - Country:US
Practice Address - Phone:206-723-9853
Practice Address - Fax:206-723-0849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022120261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7033046Medicaid
WAVE4004OtherREGENCE
WA7033046Medicaid
WA8856995Medicare ID - Type Unspecified