Healthcare Provider Details

I. General information

NPI: 1730154329
Provider Name (Legal Business Name): SUDHA ELANGOVAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 214TH ST SE SUITE 300
BOTHELL WA
98021-4412
US

IV. Provider business mailing address

1200 12TH AVE S PACIFIC MEDICAL CENTER, BLDG QUARTERS 5
SEATTLE WA
98144-2712
US

V. Phone/Fax

Practice location:
  • Phone: 425-412-7200
  • Fax:
Mailing address:
  • Phone: 206-621-4316
  • Fax: 206-621-4076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00046277
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: