Provider Demographics
NPI:1861585127
Name:NAKAMOTO, GREG I (MD)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:I
Last Name:NAKAMOTO
Suffix:
Gender:M
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 # MS /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 1:19116 33RD AVE W
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4706
Practice Address - Country:US
Practice Address - Phone:425-771-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036474207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0039594OtherLABOR AND INDUSTRIES #
WA3328NAOtherBLUE SHIELD #
WAUS7149247OtherAETNA SPECIALIST PIN
WA8278137Medicaid
WA3328NAOtherBLUE SHIELD #
H07886Medicare UPIN
WA8278137Medicaid