Provider Demographics
NPI:1073609699
Name:MYSTKOWSKI, PAUL M (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:MYSTKOWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 116TH AVE NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3819
Mailing Address - Country:US
Mailing Address - Phone:425-454-5046
Mailing Address - Fax:
Practice Address - Street 1:1407 116TH AVE NE
Practice Address - Street 2:SUITE 200
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3819
Practice Address - Country:US
Practice Address - Phone:425-454-5046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035801207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8239667Medicaid
WA8239667Medicaid
H45627Medicare UPIN