Basic Information
| Provider Information | |||||||||
| NPI: | 1396841169 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SRINIVASAN | ||||||||
| FirstName: | RENGANATHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603971500 | ||||||||
| FaxNumber: | 3606041771 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 NE 139TH ST | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986862719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603973980 | ||||||||
| FaxNumber: | 3606041739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 12/28/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0201X | MD00047649 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Allergy & Immunology | 207K00000X | MD00047649 | WA | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 8481277 | 05 | WA | MEDICAID |