1639253313 NPI number — DR. BAHIRATHAN KRISHNADASAN MD

Table of content: DR. BAHIRATHAN KRISHNADASAN MD (NPI 1639253313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639253313 NPI number — DR. BAHIRATHAN KRISHNADASAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRISHNADASAN
Provider First Name:
BAHIRATHAN
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:
KRISHNADASAN
Provider Other First Name:
BAIYA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1639253313
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1802 YAKIMA AVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405-4499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-272-7777
Provider Business Mailing Address Fax Number:
253-426-4142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1802 YAKIMA AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-4499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-272-7777
Provider Business Practice Location Address Fax Number:
253-426-4142
Provider Enumeration Date:
10/25/2006

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: 208G00000X , with the licence number:  MD00041594 , 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: 8431710 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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