Provider Demographics
NPI:1396841169
Name:SRINIVASAN, RENGANATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RENGANATHAN
Middle Name:
Last Name:SRINIVASAN
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 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-397-1500
Mailing Address - Fax:360-604-1771
Practice Address - Street 1:2525 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2719
Practice Address - Country:US
Practice Address - Phone:360-397-3980
Practice Address - Fax:360-604-1739
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00047649207RA0201X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8481277Medicaid
WA8865257Medicare PIN
I73283Medicare UPIN