Provider Demographics
NPI:1083661631
Name:GANTT, SOREN M (MD)
Entity Type:Individual
Prefix:
First Name:SOREN
Middle Name:M
Last Name:GANTT
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:PO BOX 50010
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-1010
Mailing Address - Country:US
Mailing Address - Phone:206-987-8450
Mailing Address - Fax:206-987-8484
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-1909
Practice Address - Fax:206-987-3890
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00043059208000000X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8452617Medicaid
ID807507400Medicaid
ID807507400Medicaid
WA8452617Medicaid