Healthcare Provider Details

I. General information

NPI: 1417469404
Provider Name (Legal Business Name): MAKSPORTSMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2017
Last Update Date: 10/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19110 BOTHELL WAY NE STE 102
BOTHELL WA
98011-2970
US

IV. Provider business mailing address

19110 BOTHELL WAY NE STE 102
BOTHELL WA
98011-2970
US

V. Phone/Fax

Practice location:
  • Phone: 425-286-8271
  • Fax: 425-491-7271
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number60465979
License Number StateWA

VIII. Authorized Official

Name: ABIMBOLU MAKINDE
Title or Position: OWNER
Credential: MD
Phone: 425-286-8271