Healthcare Provider Details

I. General information

NPI: 1902309313
Provider Name (Legal Business Name): LAKE WASHINGTON PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2018
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8015 SE 28TH ST STE 310
MERCER ISLAND WA
98040-2910
US

IV. Provider business mailing address

8015 SE 28TH ST STE 310
MERCER ISLAND WA
98040-2910
US

V. Phone/Fax

Practice location:
  • Phone: 206-898-2416
  • Fax: 877-771-1013
Mailing address:
  • Phone: 206-898-2416
  • Fax: 877-771-1013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33004
License Number StateWA

VIII. Authorized Official

Name: DR. ROBERT GOODE
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 206-898-2416