Provider Demographics
NPI:1629031950
Name:HINES, JOHN R (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:HINES
Suffix:
Gender:M
Credentials:DO
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 1138
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:WA
Mailing Address - Zip Code:98356-0019
Mailing Address - Country:US
Mailing Address - Phone:360-496-3688
Mailing Address - Fax:
Practice Address - Street 1:521 ADAMS AVE STE B
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:WA
Practice Address - Zip Code:98356-9323
Practice Address - Country:US
Practice Address - Phone:360-496-5145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61532255207Q00000X
ARE3472207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00115537OtherRAIL ROAD MEDICARE
AR150835003Medicaid
AR5M478OtherBLUE CROSS BLUE SHIELD INDIVIDUAL
AR5M478OtherMEDICARE INDIVIDUAL
AR5M478OtherMEDICARE INDIVIDUAL