Provider Demographics
NPI:1972584936
Name:DEAN, PHILLIP A (MD,)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:A
Last Name:DEAN
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 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:4011 TALBOT RD S STE 420
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5791
Practice Address - Country:US
Practice Address - Phone:425-690-3401
Practice Address - Fax:425-690-9401
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60513550208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2041674Medicaid
WAG8936797OtherMEDICARE W VALLEY MEDICAL GROUP - RENTON
MI4258091Medicaid
MI0N40200Medicare ID - Type Unspecified
MI0985200OtherHEALTHPLUS
MI280730282OtherBLUECROSS BLUESHIELD
MIF42502Medicare UPIN