Healthcare Provider Details

I. General information

NPI: 1194770164
Provider Name (Legal Business Name): JAISIMHA K IYENGAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 S UNION AVE STE 1A
TACOMA WA
98405-1953
US

IV. Provider business mailing address

PO BOX 111750
TACOMA WA
98411-1750
US

V. Phone/Fax

Practice location:
  • Phone: 253-627-2666
  • Fax: 253-627-8661
Mailing address:
  • Phone: 253-627-2666
  • Fax: 253-627-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberMD00036006
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: