Provider Demographics
NPI:1972681336
Name:MITSUMORI, LEE M (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:M
Last Name:MITSUMORI
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:RADIOLOGY UNIVERSITY OF WASHINGTON MEDICAL CTR
Mailing Address - Street 2:1959 NE PACIFIC STREET
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-7115
Mailing Address - Country:US
Mailing Address - Phone:206-598-0024
Mailing Address - Fax:
Practice Address - Street 1:RADIOLOGY UNIVERSITY OF WASHINGTON MEDICAL CTR
Practice Address - Street 2:1959 NE PACIFIC ST
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:206-598-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000411822085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0231575OtherL&I
4416OtherINTERNAL ID-MOTOR VEHICLE ID
WA1972681336Medicaid
WA0231575OtherL&I
H60860Medicare UPIN