Basic Information
Provider Information | |||||||||
NPI: | 1255860979 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAKSHUMANAN | ||||||||
FirstName: | SARAVANASUNDARAM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LAKSHUMANAN | ||||||||
OtherFirstName: | SARAVANA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 16110 8TH AVE SW STE A2 | ||||||||
Address2: |   | ||||||||
City: | BURIEN | ||||||||
State: | WA | ||||||||
PostalCode: | 981662962 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2062428280 | ||||||||
FaxNumber: | 2062428302 | ||||||||
Practice Location | |||||||||
Address1: | 16110 8TH AVE SW STE A2 | ||||||||
Address2: |   | ||||||||
City: | BURIEN | ||||||||
State: | WA | ||||||||
PostalCode: | 981662962 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2062428280 | ||||||||
FaxNumber: | 2062428302 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2017 | ||||||||
LastUpdateDate: | 09/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MDY61127526 | WA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD61127526 | WA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | MD61127526 | WA | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 2175512 | 05 | WA |   | MEDICAID |