Healthcare Provider Details

I. General information

NPI: 1417066556
Provider Name (Legal Business Name): KEVIN REID JOSEPH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 43RD ST
RENTON WA
98055-5714
US

IV. Provider business mailing address

3600 LIND AVE SW SUITE 100 ATTN CREDENTIALING
RENTON WA
98057-4970
US

V. Phone/Fax

Practice location:
  • Phone: 425-656-5566
  • Fax: 425-656-5567
Mailing address:
  • Phone: 425-690-2715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License NumberOP60146312
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License NumberOP60146312
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberOP60146312
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: