Provider Demographics
NPI:1861631459
Name:SUNIDJA, ADITYA PANDU (MD)
Entity Type:Individual
Prefix:
First Name:ADITYA
Middle Name:PANDU
Last Name:SUNIDJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1535
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98401-1535
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-383-3553
Practice Address - Street 1:1304 FAWCETT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1911
Practice Address - Country:US
Practice Address - Phone:253-761-4200
Practice Address - Fax:253-383-3553
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD600824422085R0202X
MA235938174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8883319OtherPTAN-TRA KING CO
WA2001567Medicaid
WAG8882744OtherPTAN-TRA PIERCE CO
WA0252135OtherLABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST
WAG8883121OtherPTAN-MIO1
WAG8882901OtherPTAN-UAOM
WAR174972OtherPTAN-PENDLETON, OREGON
WA0252135OtherLABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST
WAG8883319OtherPTAN-TRA KING CO