Provider Demographics
NPI:1629046461
Name:LOHAVANICHBUTR, PAWADEE (MD)
Entity Type:Individual
Prefix:
First Name:PAWADEE
Middle Name:
Last Name:LOHAVANICHBUTR
Suffix:
Gender:F
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 329
Mailing Address - Street 2:835 E FAIRHAVEN AVE
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-0329
Mailing Address - Country:US
Mailing Address - Phone:360-755-0641
Mailing Address - Fax:360-755-1405
Practice Address - Street 1:835 E FAIRHAVEN AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-0329
Practice Address - Country:US
Practice Address - Phone:360-755-0641
Practice Address - Fax:360-755-1405
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8433567Medicaid
WA8433567Medicaid
I21144Medicare UPIN