Healthcare Provider Details

I. General information

NPI: 1962518944
Provider Name (Legal Business Name): PEGGY D. HEADSTROM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 BROADWAY
SEATTLE WA
98122-4201
US

IV. Provider business mailing address

1145 BROADWAY
SEATTLE WA
98122-4201
US

V. Phone/Fax

Practice location:
  • Phone: 206-329-1760
  • Fax:
Mailing address:
  • Phone: 206-329-1760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD00040134
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: