Healthcare Provider Details

I. General information

NPI: 1538162854
Provider Name (Legal Business Name): JAMES IVAN MAEDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 JASMINE ST
OMAK WA
98841-9589
US

IV. Provider business mailing address

PO BOX 793
OMAK WA
98841-0793
US

V. Phone/Fax

Practice location:
  • Phone: 509-826-1600
  • Fax: 509-826-3633
Mailing address:
  • Phone: 509-826-7635
  • Fax: 509-826-7211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60069028
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: