Provider Demographics
NPI:1467915710
Name:MOMOHARA, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MOMOHARA
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:PO BOX 83
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-0083
Mailing Address - Country:US
Mailing Address - Phone:206-880-3224
Mailing Address - Fax:
Practice Address - Street 1:12911 BEVERLY PARK RD
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98087-5127
Practice Address - Country:US
Practice Address - Phone:206-880-3224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61657954208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation