Provider Demographics
NPI:1649342494
Name:LINDSTROM, PHILIP (DO)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:LINDSTROM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:PHILIP
Other - Middle Name:
Other - Last Name:CREW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:KAISER PERMENENTE MEDICAL OFFICE
Mailing Address - Street 2:14406 NE 20TH AVE
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-1448
Mailing Address - Country:US
Mailing Address - Phone:831-588-3011
Mailing Address - Fax:360-571-3110
Practice Address - Street 1:KAISER PERMENENTE MEDICAL OFFICE
Practice Address - Street 2:14406 NE 20TH AVE
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1448
Practice Address - Country:US
Practice Address - Phone:831-588-3011
Practice Address - Fax:360-571-3110
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60907414207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX70240Medicaid
002A70240Medicare ID - Type Unspecified
CA00AX70240Medicaid