Healthcare Provider Details

I. General information

NPI: 1306957345
Provider Name (Legal Business Name): ROGER PERRY TATUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 S COLUMBIAN WAY S-112-GS
SEATTLE WA
98108-1532
US

IV. Provider business mailing address

1660 S COLUMBIAN WAY S-112-GS
SEATTLE WA
98108-1532
US

V. Phone/Fax

Practice location:
  • Phone: 206-764-2141
  • Fax: 206-764-2529
Mailing address:
  • Phone: 206-764-2141
  • Fax: 206-764-2529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD00039673
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: