Basic Information
| Provider Information | |||||||||
| NPI: | 1770539991 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAXOOD | ||||||||
| FirstName: | S | ||||||||
| MiddleName: | STEVEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095225731 | ||||||||
| FaxNumber: | 5095225747 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W POPLAR ST | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993622846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095225731 | ||||||||
| FaxNumber: | 5095225747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD00039933 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | MD00039933 | 01 | WA | STATE LICENSE NUMBER | OTHER | 0149754 | 01 | WA | LABOR AND INDUSTRY | OTHER | 110228191 | 01 | WA | RAILROAD MEDICARE | OTHER | 8277857 | 05 | WA | MEDICAID |