Healthcare Provider Details

I. General information

NPI: 1730534801
Provider Name (Legal Business Name): PETER MITCHELL KALLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 9TH AVE MS:X10-ON
SEATTLE WA
98101-2756
US

IV. Provider business mailing address

1100 9TH AVE MS:X10-ON
SEATTLE WA
98101-2756
US

V. Phone/Fax

Practice location:
  • Phone: 206-341-0895
  • Fax: 206-223-6921
Mailing address:
  • Phone: 206-341-0895
  • Fax: 206-223-6921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberMD61263154
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: