Provider Demographics
NPI:1669492492
Name:MOHANDESON, MICHAEL M (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:MOHANDESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:10564 5TH AVE NE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-7200
Mailing Address - Country:US
Mailing Address - Phone:206-365-1100
Mailing Address - Fax:206-365-1118
Practice Address - Street 1:10564 5TH AVE NE
Practice Address - Street 2:SUITE 301
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-7200
Practice Address - Country:US
Practice Address - Phone:206-365-1100
Practice Address - Fax:206-365-1118
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2011-11-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00016823207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1932112539OtherNPI NUMBER FOR CORPORATION
WA0017577OtherLABOR & INDUSTRIES
WA1739101Medicaid
WAM669OtherREGENCE BLUE SHIELD
1932112539OtherNPI NUMBER FOR CORPORATION
WA1739101Medicaid