Healthcare Provider Details

I. General information

NPI: 1922009885
Provider Name (Legal Business Name): GREGG K VANDEKIEFT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 LILLY RD NE
OLYMPIA WA
98506-5101
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 360-493-7230
  • Fax: 360-493-4180
Mailing address:
  • Phone: 360-486-6508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00027326
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: