Basic Information
| Provider Information | |||||||||
| NPI: | 1588685812 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DORER | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD,PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 9TH AVE | ||||||||
| Address2: | MS:M4-PFS | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981012756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065155811 | ||||||||
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| Address1: | 1100 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981012756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062236600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | MD00046178 | WA | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7972795 | 01 | WA | AETNA | OTHER | 8463630 | 05 | WA | MEDICAID | 0039575 | 01 | WA | L&I | OTHER | 5949DO | 01 | WA | BLUE SHIELD | OTHER |