Provider Demographics
NPI:1134227903
Name:TAKAHASHI, CORRIE L (MD)
Entity type:Individual
Prefix:
First Name:CORRIE
Middle Name:L
Last Name:TAKAHASHI
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 1:1100 9TH AVE
Mailing Address - Street 2:MS:M4-PFS
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:206-515-5886
Practice Address - Street 1:33501 1ST WAY S
Practice Address - Street 2:MS: A-SO
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6208
Practice Address - Country:US
Practice Address - Phone:253-838-2400
Practice Address - Fax:253-874-1637
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046210208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0039577OtherLABOR AND INDUSTRIES#
WA3867TAOtherBLUE SHIELD#
WA8470445Medicaid
WA3867TAOtherBLUE SHIELD#
WAG8916588Medicare PIN
WA8862070Medicare PIN