Provider Demographics
NPI:1134128788
Name:MICALI, ILIANA DOMENICA (MD)
Entity type:Individual
Prefix:
First Name:ILIANA
Middle Name:DOMENICA
Last Name:MICALI
Suffix:
Gender:F
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:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:253-681-6626
Mailing Address - Fax:
Practice Address - Street 1:7424 BRIDGEPORT WAY W STE 201
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-8134
Practice Address - Country:US
Practice Address - Phone:253-240-2110
Practice Address - Fax:253-240-2111
Is Sole Proprietor?:No
Enumeration Date:2005-07-16
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037682207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA912006268OtherPREMERA
WA912006268 MI8274OtherREGENCE BLUESHIELD
WA0171332OtherLABOR & INDUSTRIES
WA2225134OtherAETNA HEALTH MANAGEMENT
WA912006268OtherPROVIDER TAX ID
110229103OtherRAILROAD MEDICARE
WA912006268 98002 0000OtherTRICARE