Provider Demographics
NPI:1073658365
Name:TAMURA, WATARU (MD)
Entity type:Individual
Prefix:DR
First Name:WATARU
Middle Name:
Last Name:TAMURA
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 1:16504 9TH AVE SE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-6396
Mailing Address - Country:US
Mailing Address - Phone:425-977-4620
Mailing Address - Fax:425-745-9836
Practice Address - Street 1:11027 MERIDIAN AVE N
Practice Address - Street 2:SUITE 100
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-1705
Practice Address - Country:US
Practice Address - Phone:206-365-4492
Practice Address - Fax:206-368-3456
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60258237207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2040804Medicaid
AZ721539038OtherEIN
AZG66818Medicare UPIN
WAG8934422Medicare PIN
WA2040804Medicaid
AZZ103543Medicare PIN
COZ103543Medicare PIN