Provider Demographics
NPI:1376706028
Name:TOTEM LAKE PEDIATRICS
Entity Type:Organization
Organization Name:TOTEM LAKE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FIROZ
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-899-4570
Mailing Address - Street 1:13128 TOTEM LAKE BLVD NE STE 105
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-2953
Mailing Address - Country:US
Mailing Address - Phone:425-899-4570
Mailing Address - Fax:
Practice Address - Street 1:13128 TOTEM LAKE BLVD NE STE 105
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2953
Practice Address - Country:US
Practice Address - Phone:425-899-4570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029356261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1078922Medicaid