Healthcare Provider Details

I. General information

NPI: 1417939331
Provider Name (Legal Business Name): JAMES ROBERT FACKELMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10555 SE CARR RD
RENTON WA
98055-5820
US

IV. Provider business mailing address

PO BOX 34876
SEATTLE WA
98124-1876
US

V. Phone/Fax

Practice location:
  • Phone: 425-656-4270
  • Fax: 425-656-4271
Mailing address:
  • Phone: 425-656-5412
  • Fax: 425-656-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00024483
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: