Provider Demographics
NPI:1831900422
Name:CARBON HEALTH MEDICAL GROUP OF WASHINGTON PC
Entity type:Organization
Organization Name:CARBON HEALTH MEDICAL GROUP OF WASHINGTON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUJAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDAVIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-329-3727
Mailing Address - Street 1:1801 WEST BAY DR NW STE 202B
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 WEST BAY DR NW STE 202B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4311
Practice Address - Country:US
Practice Address - Phone:415-329-3727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty