Healthcare Provider Details

I. General information

NPI: 1174751325
Provider Name (Legal Business Name): AMY BETH DETTORI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY BETH CLARK M.D.

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3475 N SARATOGA ST BLDG 993
OAK HARBOR WA
98278-8800
US

IV. Provider business mailing address

6034 40TH AVE NE
SEATTLE WA
98115-7502
US

V. Phone/Fax

Practice location:
  • Phone: 360-257-9406
  • Fax:
Mailing address:
  • Phone: 206-765-6766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number01068606A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberMD61153930
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: