Provider Demographics
NPI:1235231929
Name:MYSTKOWSKI, SUPRIYA KELKAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SUPRIYA
Middle Name:KELKAR
Last Name:MYSTKOWSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUE
Other - Middle Name:KELKAR
Other - Last Name:MYSTKOWSKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 34036
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1036
Mailing Address - Country:US
Mailing Address - Phone:425-899-3292
Mailing Address - Fax:425-899-3269
Practice Address - Street 1:11521 NE 128TH ST STE 130
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4317
Practice Address - Country:US
Practice Address - Phone:425-899-4280
Practice Address - Fax:425-899-4294
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039430207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8283822Medicaid
WAG8880787Medicare PIN