1891807863 NPI number — DR. RUBEN KRISHNANANTHAN MD

Table of content: DR. RUBEN KRISHNANANTHAN MD (NPI 1891807863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891807863 NPI number — DR. RUBEN KRISHNANANTHAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRISHNANANTHAN
Provider First Name:
RUBEN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891807863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19020 33RD AVE W STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNNWOOD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98036-4748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-563-1500
Provider Business Mailing Address Fax Number:
425-563-1374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19020 33RD AVE W
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
LYNNWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98036-4746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-563-1500
Provider Business Practice Location Address Fax Number:
425-563-1501
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  MD00045187 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207U00000X , with the licence number: MD00045187 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0356361 . This is a "L&I-RADIA-REST OF WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0356365 . This is a "L&I-SWEDISH RADIA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0356366 . This is a "L&I-EVERGREEN RADIA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1021587 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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