Healthcare Provider Details

I. General information

NPI: 1982947149
Provider Name (Legal Business Name): DEIRDRE KNOBELOCH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 N 115TH ST STE 101
SEATTLE WA
98133
US

IV. Provider business mailing address

9447 HOLY CROSS LN
BREESE IL
62230-3510
US

V. Phone/Fax

Practice location:
  • Phone: 206-668-6806
  • Fax: 206-668-6808
Mailing address:
  • Phone: 206-668-6806
  • Fax: 206-668-6808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberOP60824606
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036150182
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: