Provider Demographics
NPI:1548294150
Name:DEER PARK FAMILY CARE CLINIC PS
Entity type:Organization
Organization Name:DEER PARK FAMILY CARE CLINIC PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTICIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:A
Authorized Official - Last Name:FIGUEROA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-276-5005
Mailing Address - Street 1:PO BOX 1529
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-1529
Mailing Address - Country:US
Mailing Address - Phone:509-276-5005
Mailing Address - Fax:509-276-6785
Practice Address - Street 1:905 E D ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006
Practice Address - Country:US
Practice Address - Phone:509-276-5005
Practice Address - Fax:509-276-6785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QR1300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7085640Medicaid
WA7118326Medicaid
WA7118326Medicaid
WA503885Medicare Oscar/Certification