Provider Demographics
NPI:1710969696
Name:SIMANGAN, MARIO DODDS ROSALES (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:DODDS ROSALES
Last Name:SIMANGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DODDS
Other - Middle Name:R
Other - Last Name:SIMANGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:800 WEST MAPLE STREET
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-0800
Mailing Address - Country:US
Mailing Address - Phone:509-565-4000
Mailing Address - Fax:509-565-7015
Practice Address - Street 1:800 WEST MAPLE STREET
Practice Address - Street 2:
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022-0800
Practice Address - Country:US
Practice Address - Phone:509-565-4000
Practice Address - Fax:509-565-7015
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000219812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1087626Medicaid
WAE87263Medicare UPIN
WA1087626Medicaid