Healthcare Provider Details

I. General information

NPI: 1770598112
Provider Name (Legal Business Name): JUDE GERARD D VERZOSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
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 TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00042893
License Number StateWA

VII. Legacy identifiers

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

# 1
Identifier0194113
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerSTATE L&I
# 2
Identifier1045610
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 3
Identifier8904491
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerSTATE CRIME VICTIMS
# 4
Identifier8939176
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerSTATE CRIME VICTIMS
# 5
Identifier0184016
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerSTATE L&I
# 6
IdentifierP00143183
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerMEDICARE RAILROAD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: