Provider Demographics
NPI:1649454026
Name:MICHAEL L. TJOELKER, M.D.
Entity type:Organization
Organization Name:MICHAEL L. TJOELKER, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:TJOELKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-259-0049
Mailing Address - Street 1:3327 COLBY AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-6403
Mailing Address - Country:US
Mailing Address - Phone:425-259-0049
Mailing Address - Fax:425-258-6403
Practice Address - Street 1:3327 COLBY AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-6403
Practice Address - Country:US
Practice Address - Phone:425-259-0049
Practice Address - Fax:425-258-6403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022643207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1000892Medicaid
WA1000892Medicaid