Provider Demographics
NPI:1144364605
Name:SUSANTO, DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:SUSANTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W STE 210
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4748
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:No
Enumeration Date:2007-02-17
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN176872085R0202X
WAMD600834852085R0202X, 2085N0700X
AKS-79002085R0202X
IDM-123782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1144364605Medicaid
WA263299OtherLNI
AK1584895Medicaid
WA263302OtherLNI
WA263305OtherLNI
WA2007663Medicaid
WAP00979807Medicare PIN
WAP00889310Medicare PIN
WA2007663Medicaid
ID1144364605Medicaid
WAG8892407Medicare PIN
WAG8892408Medicare PIN
WAG8892406Medicare PIN