Provider Demographics
NPI:1689645285
Name:BOHORFOUSH, ANTHONY G III (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:G
Last Name:BOHORFOUSH
Suffix:III
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:206-520-5700
Mailing Address - Fax:
Practice Address - Street 1:1560 N 115TH ST
Practice Address - Street 2:SUITE 207
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8414
Practice Address - Country:US
Practice Address - Phone:206-668-1341
Practice Address - Fax:206-668-1342
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025454207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1689645285Medicaid
WA8949016Medicare PIN
WA1039427Medicaid