Healthcare Provider Details

I. General information

NPI: 1376176594
Provider Name (Legal Business Name): GEORGIY O BONDARCHUK DIVE IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W MARINE VIEW DR BLDG 2202
EVERETT WA
98207-5000
US

IV. Provider business mailing address

18151 68TH AVE NE APT 317
KENMORE WA
98028-2834
US

V. Phone/Fax

Practice location:
  • Phone: 425-304-5504
  • Fax:
Mailing address:
  • Phone: 425-304-5504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: