Basic Information
| Provider Information | |||||||||
| NPI: | 1124281076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETTORI | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11511 NE 10TH ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980048578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255023000 | ||||||||
| FaxNumber: | 4255023589 | ||||||||
| Practice Location | |||||||||
| Address1: | 2930 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982013832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252611500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD60236693 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207W00000X | MD60236693 | WA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.