Provider Demographics
NPI:1528139524
Name:MITO, ROBERT K (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:K
Last Name:MITO
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:PO BOX 84026
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-8426
Mailing Address - Country:US
Mailing Address - Phone:425-744-1777
Mailing Address - Fax:
Practice Address - Street 1:7320 216TH ST SW STE 210
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8006
Practice Address - Country:US
Practice Address - Phone:425-744-1777
Practice Address - Fax:425-744-1790
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016218207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1106244Medicaid
A 05197Medicare UPIN
WAAB10162Medicare PIN