Provider Demographics
NPI:1952480899
Name:PODIATRIC PHYSICIANS AND SURGEONS P.S.
Entity Type:Organization
Organization Name:PODIATRIC PHYSICIANS AND SURGEONS P.S.
Other - Org Name:DR. RONALD KRIVOSHA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR OF PODIATRIC MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:KRIVOSHA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:425-453-1598
Mailing Address - Street 1:11711 NE 12TH ST
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2461
Mailing Address - Country:US
Mailing Address - Phone:425-453-1498
Mailing Address - Fax:425-450-0029
Practice Address - Street 1:11711 NE 12TH ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005
Practice Address - Country:US
Practice Address - Phone:425-453-1598
Practice Address - Fax:425-450-0029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP0OOO177213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1477405Medicaid
WA1010701Medicaid
WA0059835OtherLABOR AND INDURSTRY
WA1C 000102875Medicare PIN
WA1010701Medicaid
WA0059835OtherLABOR AND INDURSTRY