Healthcare Provider Details

I. General information

NPI: 1972539401
Provider Name (Legal Business Name): OVERLAKE OBSTETRICIANS & GYNECOLOGIST P S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 116TH AVE NE SUITE 950
BELLEVUE WA
98004-3804
US

IV. Provider business mailing address

1231 116TH AVE NE SUITE 950
BELLEVUE WA
98004-3804
US

V. Phone/Fax

Practice location:
  • Phone: 425-454-3366
  • Fax: 425-460-5954
Mailing address:
  • Phone: 425-454-3366
  • Fax: 425-460-5954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number600035651
License Number StateWA

VIII. Authorized Official

Name: JONATHAN I PALEY
Title or Position: PRESIDENT
Credential: MD
Phone: 425-943-3230