Healthcare Provider Details

I. General information

NPI: 1629241112
Provider Name (Legal Business Name): OVERLAKE FAMILY VISION, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 05/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 116TH AVE NE STE120
BELLEVUE WA
98004-4626
US

IV. Provider business mailing address

1135 116TH AVE NE STE120
BELLEVUE WA
98004-4626
US

V. Phone/Fax

Practice location:
  • Phone: 425-638-0700
  • Fax:
Mailing address:
  • Phone: 425-638-0700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number1995TX
License Number StateWA

VIII. Authorized Official

Name: DR. MARY E BAKER
Title or Position: OWNER
Credential: OD
Phone: 425-638-0700