Provider Demographics
NPI:1184691370
Name:ITO, SIRI EIKO (MD)
Entity type:Individual
Prefix:
First Name:SIRI
Middle Name:EIKO
Last Name:ITO
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 1:14701 179TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1108
Mailing Address - Country:US
Mailing Address - Phone:360-794-1447
Mailing Address - Fax:360-794-1485
Practice Address - Street 1:14701 179TH AVE SE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1108
Practice Address - Country:US
Practice Address - Phone:360-794-1447
Practice Address - Fax:360-794-1485
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037809207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8276347Medicaid
WA8276347Medicaid
WAH36157Medicare UPIN