Healthcare Provider Details

I. General information

NPI: 1477553246
Provider Name (Legal Business Name): JULIO F BUENAVENTURA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 05/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 92ND AVENUE CT SW
LAKEWOOD WA
98498-3973
US

IV. Provider business mailing address

7501 92ND AVENUE CT SW
LAKEWOOD WA
98498-3973
US

V. Phone/Fax

Practice location:
  • Phone: 253-588-0058
  • Fax: 253-589-4862
Mailing address:
  • Phone: 253-588-0058
  • Fax: 253-589-4862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00009747
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: