Healthcare Provider Details

I. General information

NPI: 1164490892
Provider Name (Legal Business Name): WALTER QUINTON GRADEK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E JEFFERSON ST STE 600
SEATTLE WA
98122
US

IV. Provider business mailing address

PO BOX 25608
SALT LAKE CITY UT
84125-0608
US

V. Phone/Fax

Practice location:
  • Phone: 206-861-8550
  • Fax: 206-861-8551
Mailing address:
  • Phone: 206-320-4476
  • Fax: 206-568-7043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number046107
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD60917858
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: