Provider Demographics
NPI:1205891181
Name:RAMACHANDRAN, MYTHILI R (MD)
Entity type:Individual
Prefix:DR
First Name:MYTHILI
Middle Name:R
Last Name:RAMACHANDRAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21509 HWY 410 E
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-4190
Mailing Address - Country:US
Mailing Address - Phone:253-891-2160
Mailing Address - Fax:253-891-2171
Practice Address - Street 1:17500 SE 392ND ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98092-9705
Practice Address - Country:US
Practice Address - Phone:253-294-8201
Practice Address - Fax:253-333-3612
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036489207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1117456Medicaid
201130800OtherDOL
WA5801754OtherAETNA
WA126641OtherLABOR & INDUSTRIES
P00070741OtherMEDICARE RAILROAD
WAAR6157OtherREGENCE BLUE SHEILD RIDER
BA6173493OtherDEA NUMBER
WAG93639Medicare UPIN
WAGAB33123Medicare PIN