Provider Demographics
NPI:1750527743
Name:HOLBERT, DANIEL VERNON (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:VERNON
Last Name:HOLBERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W STE 210
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4748
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD600258472085R0202X, 2085R0204X
IDM-122782085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1750527743Medicaid
WA0404518OtherL&I-SEATTLE RADIOLOGY
WA0310078OtherL&I-RADIA REST OF WA
WA2022757Medicaid
WA0310079OtherL&I-SWEDISH RADIA EDMONDS
WA1750527743Medicaid
WA0310080OtherL&I-EVERGREEN RADIA
WA0378809OtherL&I-RADIA KING CTY
WA310080OtherLNI PROVIDER ID
WA2022757Medicaid
WAG8911661Medicare PIN
WAP01109103Medicare PIN
WAG8911663Medicare PIN
WAG8911660Medicare PIN