Healthcare Provider Details

I. General information

NPI: 1285079145
Provider Name (Legal Business Name): EDUARDO VISITACION DUQUEZ JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2013
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 GRIFFIN AVE
ENUMCLAW WA
98022-2369
US

IV. Provider business mailing address

3021 GRIFFIN AVE
ENUMCLAW WA
98022-2369
US

V. Phone/Fax

Practice location:
  • Phone: 360-825-6511
  • Fax: 253-274-7993
Mailing address:
  • Phone: 360-825-6511
  • Fax: 253-274-7993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number60646801
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberQ2761
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60646799
License Number StateWA

VII. Legacy identifiers

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

# 1
Identifier2061924
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: