Healthcare Provider Details

I. General information

NPI: 1861493272
Provider Name (Legal Business Name): EASTSIDE ENDOCRINOLOGY AND DIABETES, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 116TH AVE NE SUITE 150
BELLEVUE WA
98004-3059
US

IV. Provider business mailing address

2020 116TH AVE NE SUITE 150
BELLEVUE WA
98004-3059
US

V. Phone/Fax

Practice location:
  • Phone: 425-453-9762
  • Fax: 425-455-5953
Mailing address:
  • Phone: 425-453-9762
  • Fax: 425-455-5953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD00024156
License Number StateWA

VIII. Authorized Official

Name: DR. BRADLEY JOY WALLUM
Title or Position: OWNER
Credential: MD
Phone: 425-453-9762