Provider Demographics
NPI:1235182122
Name:DAGAN, BENIGNO WALDO A (MD)
Entity Type:Individual
Prefix:DR
First Name:BENIGNO WALDO
Middle Name:A
Last Name:DAGAN
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 1:1420 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390
Mailing Address - Country:US
Mailing Address - Phone:253-987-5156
Mailing Address - Fax:253-987-5462
Practice Address - Street 1:1420 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390
Practice Address - Country:US
Practice Address - Phone:253-987-5156
Practice Address - Fax:253-987-5462
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036169207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5496722OtherAETNA PROVIDER NUMBER
WA0185591OtherL & I PROVIDER NUMBER
WA2004507Medicaid
WA98390A015OtherTRICARE PROVIDER NUMBER
WA9869DAOtherREGENCE RIDER NUMBER
WA911203494BPOtherKPS PROVIDER NUMBER
WAG76831Medicare UPIN
WA2004507Medicaid