Healthcare Provider Details

I. General information

NPI: 1235577883
Provider Name (Legal Business Name): KENNETH Y IGBALODE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 TALBOT RD S STE 500
RENTON WA
98055-5782
US

IV. Provider business mailing address

3600 LIND AVE SW SUITE 100 ATTN CREDENTIALING
RENTON WA
98057-4970
US

V. Phone/Fax

Practice location:
  • Phone: 425-690-3482
  • Fax: 425-690-9082
Mailing address:
  • Phone: 425-690-2715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL-255187
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD61041046
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: