Healthcare Provider Details

I. General information

NPI: 1679148043
Provider Name (Legal Business Name): KOUSHIK VARMA SANGARAJU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 COLLEGE ST SE
LACEY WA
98503-4389
US

IV. Provider business mailing address

4800 COLLEGE ST SE
LACEY WA
98503-4389
US

V. Phone/Fax

Practice location:
  • Phone: 360-413-4250
  • Fax: 360-412-2262
Mailing address:
  • Phone: 360-413-4250
  • Fax: 360-412-2262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD.MD.70105939
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: