Provider Demographics
NPI:1548319791
Name:VESSELLE, LOREN J (MD)
Entity type:Individual
Prefix:
First Name:LOREN
Middle Name:J
Last Name:VESSELLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 OLIVE WAY MSC M4-PA
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1873
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:
Practice Address - Street 1:13014 120TH AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3015
Practice Address - Country:US
Practice Address - Phone:425-821-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034975207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAVE4510OtherBLUE SHIELD #
WAUS0864190OtherAETNA SPECIALIST PIN
WA0039593OtherLABOR AND INDUSTRIES #
WA8209975Medicaid
WAAB03569Medicare PIN
WA0039593OtherLABOR AND INDUSTRIES #
G50486Medicare UPIN