Provider Demographics
NPI:1669492492
Name:MOHANDESON, MICHAEL M (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:MOHANDESON
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:P.O. BOX 233
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020
Mailing Address - Country:US
Mailing Address - Phone:206-365-1100
Mailing Address - Fax:206-365-1118
Practice Address - Street 1:P.O. BOX 233
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020
Practice Address - Country:US
Practice Address - Phone:425-399-6441
Practice Address - Fax:206-365-1118
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016823207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1739101Medicaid
WA0017577OtherLABOR & INDUSTRIES
1932112539OtherNPI NUMBER FOR CORPORATION
WAM669OtherREGENCE BLUE SHIELD
1932112539OtherNPI NUMBER FOR CORPORATION
WA1739101Medicaid