Healthcare Provider Details

I. General information

NPI: 1215007091
Provider Name (Legal Business Name): JOEL C KONIKOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BROADWAY SUITE 530
SEATTLE WA
98122-5229
US

IV. Provider business mailing address

PO BOX 1643
MERCER ISLAND WA
98040-1643
US

V. Phone/Fax

Practice location:
  • Phone: 206-789-5418
  • Fax: 206-784-9744
Mailing address:
  • Phone: 206-789-5418
  • Fax: 206-784-9744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD00014204
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: