Provider Demographics
NPI:1912423468
Name:VINTAGE DIRECT PRIMARY CARE
Entity type:Organization
Organization Name:VINTAGE DIRECT PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LEHMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-860-3020
Mailing Address - Street 1:19319 7TH AVE NE STE 114
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7442
Mailing Address - Country:US
Mailing Address - Phone:360-930-3500
Mailing Address - Fax:
Practice Address - Street 1:25985 BARBR CUTFF RD NE STE B1
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-9596
Practice Address - Country:US
Practice Address - Phone:360-860-3020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00033623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty