Provider Demographics
NPI:1275623795
Name:ALEDO, ERENIO KEONI SR (MD)
Entity Type:Individual
Prefix:DR
First Name:ERENIO
Middle Name:KEONI
Last Name:ALEDO
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KEONI
Other - Middle Name:
Other - Last Name:ALEDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:515 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-3737
Mailing Address - Country:US
Mailing Address - Phone:509-547-2204
Mailing Address - Fax:509-542-8836
Practice Address - Street 1:515 W COURT ST
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-3737
Practice Address - Country:US
Practice Address - Phone:509-547-2204
Practice Address - Fax:509-542-8836
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 25804207Q00000X
WAMD60225575207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213505Medicaid
WAG8903400Medicare PIN
I38948Medicare UPIN
132308Medicare ID - Type Unspecified