Provider Demographics
NPI:1811040173
Name:ESTRADA, JOEL FAUSTO KLIATCHKO (MD)
Entity Type:Individual
Prefix:
First Name:JOEL FAUSTO
Middle Name:KLIATCHKO
Last Name:ESTRADA
Suffix:
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 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:206-764-0112
Mailing Address - Fax:206-764-0489
Practice Address - Street 1:1701 3RD ST SE
Practice Address - Street 2:SUITE 300
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-4511
Practice Address - Country:US
Practice Address - Phone:253-697-5767
Practice Address - Fax:253-697-5682
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041954207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8370488Medicaid
WA8370488Medicaid
I21440Medicare UPIN