Provider Demographics
NPI:1508941204
Name:STEPHANE, MASSOUD (MD)
Entity Type:Individual
Prefix:DR
First Name:MASSOUD
Middle Name:
Last Name:STEPHANE
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 1:4030 LAKE WASHINGTON BLVD NE STE 303
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-7870
Mailing Address - Country:US
Mailing Address - Phone:253-752-7320
Mailing Address - Fax:
Practice Address - Street 1:4030 LAKE WASHINGTON BLVD NE STE 303
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-7870
Practice Address - Country:US
Practice Address - Phone:253-752-7320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00528162084P0800X
WAMD614134852084P0800X
IN01077111A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201369440Medicaid
IN116660025Medicare PIN