Provider Demographics
NPI:1386833846
Name:KITAHATA, MARI M (MD)
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:M
Last Name:KITAHATA
Suffix:
Gender:F
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:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:325 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2499
Practice Address - Country:US
Practice Address - Phone:206-744-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028458207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8126468Medicaid
WAAB25276Medicare PIN
WA000107595Medicare PIN
WA8126468Medicaid