Provider Demographics
NPI:1225244379
Name:CUSTODIO, HIPOLITO MANCE III (MD)
Entity Type:Individual
Prefix:
First Name:HIPOLITO
Middle Name:MANCE
Last Name:CUSTODIO
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:550 GAGE BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:945 GOETHALS DR
Practice Address - Street 2:SUITE 200
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3552
Practice Address - Country:US
Practice Address - Phone:509-942-2555
Practice Address - Fax:509-942-2340
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMT186614207V00000X
WAMD60074660207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0249026OtherLABOR & INDUSTRIES
WA8544694Medicaid
WA8882856Medicare PIN