Provider Demographics
NPI:1477542447
Name:NIKOMBORIRAK, JAKDEJ (MD)
Entity Type:Individual
Prefix:
First Name:JAKDEJ
Middle Name:
Last Name:NIKOMBORIRAK
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:PO BOX 11648
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-5648
Mailing Address - Country:US
Mailing Address - Phone:360-344-3701
Mailing Address - Fax:360-344-3702
Practice Address - Street 1:9638 NE LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-1115
Practice Address - Country:US
Practice Address - Phone:360-344-3701
Practice Address - Fax:360-344-3702
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036445207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG69338Medicare UPIN