Provider Demographics
NPI:1649296971
Name:WITHAM, ROBERT R (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:WITHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3920 CAPITAL MALL DR SW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8701
Mailing Address - Country:US
Mailing Address - Phone:360-753-4700
Mailing Address - Fax:360-753-6700
Practice Address - Street 1:3920 CAPITAL MALL DR SW
Practice Address - Street 2:SUITE 100
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8701
Practice Address - Country:US
Practice Address - Phone:360-753-4700
Practice Address - Fax:360-753-6700
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00017298207R00000X, 207RG0100X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1506807Medicaid
WAA08011Medicare UPIN
WAG000500174Medicare ID - Type Unspecified