Provider Demographics
NPI:1578610721
Name:TRIVISONNO, RODOLFO ANIBAL (MD)
Entity Type:Individual
Prefix:DR
First Name:RODOLFO
Middle Name:ANIBAL
Last Name:TRIVISONNO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-7717
Mailing Address - Country:US
Mailing Address - Phone:425-252-9216
Mailing Address - Fax:425-252-8637
Practice Address - Street 1:319 119TH DRIVE SE
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-7717
Practice Address - Country:US
Practice Address - Phone:425-948-7893
Practice Address - Fax:425-948-7943
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000347392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA202833OtherLABOR AND INDUSTRIES
WA8214850Medicaid
WA4890RTOtherREGENCE
WA553011OtherVALUE OPTION
WA4890RTOtherREGENCE