Healthcare Provider Details

I. General information

NPI: 1578774956
Provider Name (Legal Business Name): LISA CAROL OLMOS DE KOO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA CAROL OLMOS M.D.

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 JEFFERSON ST
SEATTLE WA
98104-2433
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 206-744-2020
  • Fax:
Mailing address:
  • Phone: 206-543-6420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD60669002
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: