Provider Demographics
NPI:1720066293
Name:WITRAK, BONNIE J (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:J
Last Name:WITRAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W STE 210
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4748
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-124232085N0700X, 2085R0202X
WAMD000228962085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1720066293Medicaid
WA117424OtherL&I PROVIDER NUMBER
WA120220OtherL&I PROVIDER NUMBER
WA224089OtherL&I PROVIDER NUMBER
WA8131740Medicaid
WA204125OtherL&I PROVIDER NUMBER
WAG8880255Medicare PIN
WA204125OtherL&I PROVIDER NUMBER
WAG8872077Medicare UPIN
WA8862845Medicare PIN
WAG8890387Medicare PIN
WA224089OtherL&I PROVIDER NUMBER
WA8131740Medicaid
WAP01224314Medicare PIN
ID1720066293Medicaid
WAG8918982Medicare PIN
WAGAB02897Medicare PIN
WAP300076946Medicare PIN