=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336295864
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KALYAN DANDALA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 07/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 120TH AVE NE SUITE 201
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98005-2135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-283-4200
-----------------------------------------------------
Fax | 425-458-7528
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 819 VIRGINIA ST UNIT 3107
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98101-4421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-708-6877
-----------------------------------------------------
Fax | 206-708-6877
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0802X
-----------------------------------------------------
Taxonomy Name | Addiction Psychiatry Physician
-----------------------------------------------------
License Number | MD00048010
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD00048010
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084A0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number | MD00048010
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | MD00048010
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------