1396772760 NPI number — DR. GEOFFREY E SULTANA M.D.

Table of content: DR. GEOFFREY E SULTANA M.D. (NPI 1396772760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396772760 NPI number — DR. GEOFFREY E SULTANA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULTANA
Provider First Name:
GEOFFREY
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1396772760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2078
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98071-2078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-293-5453
Provider Business Mailing Address Fax Number:
866-581-5147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 N DIVISION ST
Provider Second Line Business Practice Location Address:
400
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98001-4939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-293-5453
Provider Business Practice Location Address Fax Number:
866-581-5147
Provider Enumeration Date:
06/28/2006

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: 208100000X , with the licence number:  4301080108 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: MD60011758 , 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: 0238519 . This is a "LABOR AND INDUSTTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2696239 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8525024 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3114SU . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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