1902891104 NPI number — DR. PAULO J CANCADO M.D.

Table of content: DR. PAULO J CANCADO M.D. (NPI 1902891104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902891104 NPI number — DR. PAULO J CANCADO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANCADO
Provider First Name:
PAULO
Provider Middle Name:
J
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:
1902891104
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
216 W 10TH AVE
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
KENNEWICK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99336-6304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-585-5972
Provider Business Mailing Address Fax Number:
509-586-5701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
216 W 10TH AVE
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336-6300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-585-5972
Provider Business Practice Location Address Fax Number:
509-586-5701
Provider Enumeration Date:
09/13/2005

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: 2084N0400X , with the licence number:  MD0000033734 , 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: 1116714 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8936953 . This is a "CRIME VICTIMS NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0160721 . This is a "LABOR & INDUSTRIES #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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