Provider Demographics
NPI:1174751325
Name:DETTORI, AMY BETH (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:BETH
Last Name:DETTORI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:BETH
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6034 40TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-7502
Mailing Address - Country:US
Mailing Address - Phone:206-765-6766
Mailing Address - Fax:
Practice Address - Street 1:3475 N SARATOGA ST
Practice Address - Street 2:BLDG 993
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98278-8800
Practice Address - Country:US
Practice Address - Phone:360-257-9406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068606A2083A0100X
390200000X
WAMD611539302080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program