Provider Demographics
NPI:1932112539
Name:MICHAEL MOHANDESON, MD PS
Entity Type:Organization
Organization Name:MICHAEL MOHANDESON, MD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATION PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOHANDESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-365-1100
Mailing Address - Street 1:10564 5TH AVE NE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125
Mailing Address - Country:US
Mailing Address - Phone:206-365-1100
Mailing Address - Fax:206-365-1118
Practice Address - Street 1:10564 5TH AVE NE
Practice Address - Street 2:SUITE 301
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125
Practice Address - Country:US
Practice Address - Phone:206-365-1100
Practice Address - Fax:206-365-1118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA16823207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1739101Medicaid
WA1739101Medicaid
A05200Medicare UPIN