Provider Demographics
NPI:1063407179
Name:VISHEVSKY, ILYA (RDMS)
Entity type:Individual
Prefix:MR
First Name:ILYA
Middle Name:
Last Name:VISHEVSKY
Suffix:
Gender:M
Credentials:RDMS
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 33879
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-0879
Mailing Address - Country:US
Mailing Address - Phone:425-235-5984
Mailing Address - Fax:425-226-6331
Practice Address - Street 1:1611 116TH AVE NE STE 207
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3063
Practice Address - Country:US
Practice Address - Phone:425-235-5984
Practice Address - Fax:425-226-6331
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7072663Medicaid
WAGAB06983Medicare PIN