Provider Demographics
NPI:1023281623
Name:ENUMCLAW INTERNAL MEDICINE AND DIAGNOSTICS, PS
Entity type:Organization
Organization Name:ENUMCLAW INTERNAL MEDICINE AND DIAGNOSTICS, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EMITIS
Authorized Official - Middle Name:K
Authorized Official - Last Name:HOSODA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-802-0803
Mailing Address - Street 1:1427 JEFFERSON AVE
Mailing Address - Street 2:SUITE # 102
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-3649
Mailing Address - Country:US
Mailing Address - Phone:360-802-0803
Mailing Address - Fax:360-802-0806
Practice Address - Street 1:1427 JEFFERSON AVE
Practice Address - Street 2:SUITE # 102
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3649
Practice Address - Country:US
Practice Address - Phone:360-802-0803
Practice Address - Fax:360-802-0806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB28545Medicare PIN