Provider Demographics
NPI:1588638670
Name:SOULAKVELIDZE, IRAKLI (MD)
Entity Type:Individual
Prefix:
First Name:IRAKLI
Middle Name:
Last Name:SOULAKVELIDZE
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 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 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:206-598-4260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2012-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040470207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1588638670Medicaid
WA0202973OtherLI
WA0202973OtherLI
WA8869386Medicare PIN