Provider Demographics
NPI:1720091465
Name:ZAMORA, IVAN A (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:A
Last Name:ZAMORA
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 1:3600 LIND AVE SW
Mailing Address - Street 2:STE 100
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-4934
Mailing Address - Country:US
Mailing Address - Phone:425-656-5412
Mailing Address - Fax:
Practice Address - Street 1:4011 TALBOT RD S
Practice Address - Street 2:STE 420
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5773
Practice Address - Country:US
Practice Address - Phone:425-656-5430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016577208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1397504Medicaid
WAA55515Medicare UPIN
WA1397504Medicaid