Healthcare Provider Details

I. General information

NPI: 1609292002
Provider Name (Legal Business Name): BENJAMIN WALTER DONALD ILES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2014
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 17TH AVE
SEATTLE WA
98122-5711
US

IV. Provider business mailing address

19020 33RD AVE W STE 210
LYNNWOOD WA
98036-4748
US

V. Phone/Fax

Practice location:
  • Phone: 206-320-3700
  • Fax: 206-320-5955
Mailing address:
  • Phone: 425-563-1500
  • Fax: 425-563-1374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberOP61040926
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number5101025913
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOP61040926
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: