Provider Demographics
NPI:1396783940
Name:PONRAJ, EDSON GERRY (MD)
Entity type:Individual
Prefix:
First Name:EDSON
Middle Name:GERRY
Last Name:PONRAJ
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 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:11315 BRIDGEPORT WAY SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3004
Practice Address - Country:US
Practice Address - Phone:253-589-8700
Practice Address - Fax:253-581-6588
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043988207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1186POOtherBSWA
WA8400749Medicaid
WA0186779OtherLIWA
WA0186778OtherLIWA
WA2165POOtherBSWA
WAG8851824Medicare PIN
WA1186POOtherBSWA
WA8400749Medicaid