Healthcare Provider Details

I. General information

NPI: 1912131632
Provider Name (Legal Business Name): JAY NICHOLA UMBREIT M.D, PH. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2009
Last Update Date: 05/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17625 48TH AVE SE
BOTHELL WA
98012-6792
US

IV. Provider business mailing address

PO BOX 12457
MILL CREEK WA
98082-0457
US

V. Phone/Fax

Practice location:
  • Phone: 425-949-7217
  • Fax:
Mailing address:
  • Phone: 425-949-7217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number051095
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number051095
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: