Provider Demographics
NPI:1881632420
Name:NIAMATALI, GAVIND H (MD)
Entity Type:Individual
Prefix:
First Name:GAVIND
Middle Name:H
Last Name:NIAMATALI
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 1:1717 S J ST STE 336
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4933
Mailing Address - Country:US
Mailing Address - Phone:253-426-4101
Mailing Address - Fax:253-426-6936
Practice Address - Street 1:1717 S J ST STE 336
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4933
Practice Address - Country:US
Practice Address - Phone:253-426-4101
Practice Address - Fax:253-426-6936
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045977174400000X, 208M00000X, 207R00000X
IAMD48511207R00000X
WV31696207R00000X
MEMD26379207R00000X
MIEMC0002355207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA146214Medicare UPIN
WA8447542Medicaid
WA8859325Medicare ID - Type Unspecified