Provider Demographics
NPI:1376541847
Name:HUSODO, INDRAWAN (MD)
Entity Type:Individual
Prefix:DR
First Name:INDRAWAN
Middle Name:
Last Name:HUSODO
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 1:990 SYLVAN WAY
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-2851
Mailing Address - Country:US
Mailing Address - Phone:360-479-3657
Mailing Address - Fax:360-373-7616
Practice Address - Street 1:990 SYLVAN WAY
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-2851
Practice Address - Country:US
Practice Address - Phone:360-479-3657
Practice Address - Fax:360-373-7616
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028376207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA72669OtherLABOR AND INDUSTRIES
WAHU0090OtherREGENCE BLUE SHIELD
WA8132292Medicaid
WA91084721521OtherKPS
WA06487001OtherGROUP HEALTH CORP
WA910847215OtherPREMERA BLUE CROSS
WA050042796OtherRAILROAD MEDCIARE
WA8933482OtherVICTIMS OF CRIME
WA8933482OtherVICTIMS OF CRIME
WAHU0090OtherREGENCE BLUE SHIELD