Provider Demographics
NPI:1215966635
Name:ISLAND DERMATOLOGY PLLC
Entity type:Organization
Organization Name:ISLAND DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HEUPEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-486-2340
Mailing Address - Street 1:8435 SE 68TH ST
Mailing Address - Street 2:STE 118
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040
Mailing Address - Country:US
Mailing Address - Phone:206-232-7546
Mailing Address - Fax:206-275-0805
Practice Address - Street 1:8435 SE 68TH ST
Practice Address - Street 2:STE 118
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040
Practice Address - Country:US
Practice Address - Phone:206-232-7546
Practice Address - Fax:206-275-0805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7105935Medicaid
WA7105935Medicaid