Provider Demographics
NPI:1790942886
Name:MAMBALAM, PRAVEEN KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:KUMAR
Last Name:MAMBALAM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 827
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98009-0827
Mailing Address - Country:US
Mailing Address - Phone:425-774-1538
Mailing Address - Fax:425-744-1527
Practice Address - Street 1:21616 76TH AVE W
Practice Address - Street 2:STE 102
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7512
Practice Address - Country:US
Practice Address - Phone:425-774-1538
Practice Address - Fax:425-744-1527
Is Sole Proprietor?:No
Enumeration Date:2008-05-17
Last Update Date:2023-05-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMD 00049423207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine