Basic Information
| Provider Information | |||||||||
| NPI: | 1356339345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHINNAPONGSE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 MADISON ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065051101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 MADISON ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981041306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065051101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | MD00036244 | WA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 8230971 | 05 | WA | MEDICAID |