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NPI Code Detail

MEDICARE: DR. CORNELIS DEHART JR. MD

MEDICARE: DR. CORNELIS DEHART JR. MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103T00000XPsychologistMD00046608WA

General Provider Information

NPI Number : 1760564934
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. CORNELIS DEHART JR. MD
Provider Business Mailing Address
First Line : 3857 MARTIN WAY E
Second Line :
City : OLYMPIA
State : WA
Zip : 98506-5268
Country : US
Telephone Number : 360-704-7170
Fax Number :
Provider Business Practice Location Address
First Line : 3436 MARY ELDER RD NE
Second Line :
City : OLYMPIA
State : WA
Zip : 98506-5050
Country : US
Telephone Number : 360-528-2590
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/19/2006
Last Update Date : 12/03/2008

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