Provider Demographics
NPI:1134133424
Name:SAMAVEDI, VANDITA S (MD)
Entity Type:Individual
Prefix:
First Name:VANDITA
Middle Name:S
Last Name:SAMAVEDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:STE 100
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-4934
Mailing Address - Country:US
Mailing Address - Phone:425-656-5412
Mailing Address - Fax:
Practice Address - Street 1:14410 SE PETROVITSKY RD
Practice Address - Street 2:STE 104
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-8900
Practice Address - Country:US
Practice Address - Phone:425-656-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041720207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8337461Medicaid
WA8337461Medicaid
WAG8801307Medicare PIN