Provider Demographics
NPI:1972793537
Name:KETCHUM, ERIC SMITH (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:SMITH
Last Name:KETCHUM
Suffix:
Gender:
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:PO BOX 1190
Mailing Address - Street 2:
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-4190
Mailing Address - Country:US
Mailing Address - Phone:650-799-6444
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:206-543-0065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2025-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD6009581207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0260642OtherL&I
WA1972793537Medicaid
8891759Medicare PIN