Provider Demographics
NPI:1689784043
Name:HANEVOLD, CORAL D (MD)
Entity Type:Individual
Prefix:DR
First Name:CORAL
Middle Name:D
Last Name:HANEVOLD
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 1:4800 SAND POINT WAY NE
Mailing Address - Street 2:MAILSTOP A-7931
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-3901
Mailing Address - Country:US
Mailing Address - Phone:206-987-2524
Mailing Address - Fax:206-987-2636
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:MAILSTOP A-7931
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-2524
Practice Address - Fax:206-987-2636
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000482532080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTL2833Medicaid
SCTL2833Medicaid
GA39BDBTVMedicare ID - Type UnspecifiedGA MEDICARE #