MEDICARE: DR. JOHN MICHAEL HAUTALA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	MD00019059	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MD00019059	OTHER	WA	STATE LICENSE NUMBER
3	108917	OTHER	WA	L&I NUMBER
4	HA7840	OTHER	WA	REGENCE BLUE SHIELD

General Provider Information

NPI Number	:	1174664130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN MICHAEL HAUTALA M.D.

Provider Business Mailing Address
First Line	:	1033 REGENTS BLVD
Second Line	:	SUITE 102
City	:	FIRCREST
State	:	WA
Zip	:	98466-6045
Country	:	US
Telephone Number	:	253-564-1115
Fax Number	:	253-565-4552

Provider Business Practice Location Address
First Line	:	1033 REGENTS BLVD
Second Line	:	SUITE 102
City	:	FIRCREST
State	:	WA
Zip	:	98466-6045
Country	:	US
Telephone Number	:	253-564-1115
Fax Number	:	253-565-4552

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2007
Last Update Date	:	03/07/2023

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Directions to “ DR. JOHN MICHAEL HAUTALA M.D.” Practice Location

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