Provider Demographics
NPI:1730260761
Name:WADWA, KALYAN S (MD)
Entity type:Individual
Prefix:DR
First Name:KALYAN
Middle Name:S
Last Name:WADWA
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 1:1400 E. KINCAID STREET
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:1400 E. KINCAID STREET
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4127
Practice Address - Country:US
Practice Address - Phone:360-428-2555
Practice Address - Fax:360-428-6402
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA39078207RG0100X
NE21405207RG0100X
NC9801542207RG0100X
MD48268207RG0100X
WAMD00039078207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA263671OtherLABOR & INDUSTRIES
WA8892955Medicare PIN