Provider Demographics
NPI: | 1336269265 |
---|---|
Name: | GHODKE, BASAVARAJ V (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | BASAVARAJ |
Middle Name: | V |
Last Name: | GHODKE |
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: | PO BOX 50095 |
Mailing Address - Street 2: | |
Mailing Address - City: | SEATTLE |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98145-5095 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 206-543-6420 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 325 9TH AVE |
Practice Address - Street 2: | |
Practice Address - City: | SEATTLE |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98104-2420 |
Practice Address - Country: | US |
Practice Address - Phone: | 206-731-3105 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-04-02 |
Last Update Date: | 2011-11-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | TR00042986 | 2085R0202X, 2085N0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085N0700X | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | 0231066 | Other | L&I |
WA | 1336269265 | Medicaid | |
WA | P00114521 | Other | RAILROAD MEDICARE |
WA | 1336269265 | Medicaid | |
WA | 0231066 | Other | L&I |