Healthcare Provider Details

I. General information

NPI: 1336599208
Provider Name (Legal Business Name): TEERAWIT SUPAKORNDEJ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TIM SUPAKORNDEJ MD

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15418 MAIN ST
MILL CREEK WA
98012-9030
US

IV. Provider business mailing address

7600 EVERGREEN WAY
EVERETT WA
98203-6421
US

V. Phone/Fax

Practice location:
  • Phone: 425-339-5417
  • Fax:
Mailing address:
  • Phone: 206-860-5414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2016018207
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD61047461
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: