Provider Demographics
NPI:1104801356
Name:MUENCHRATH, JOHN KELLEY (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KELLEY
Last Name:MUENCHRATH
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 18881
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4083
Mailing Address - Country:US
Mailing Address - Phone:360-596-4880
Mailing Address - Fax:360-596-4884
Practice Address - Street 1:404 YAUGER WAY SW STE 100
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8152
Practice Address - Country:US
Practice Address - Phone:360-596-4614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20565208800000X
WAMD60675016208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150295Medicaid
OR1407812365OtherNBMC NPI NUMBER-GROUP
ORCD8723OtherRR MEDICARE GROUP NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR340016121OtherRR MEDICARE PTAN NUMBER
OR150295Medicaid
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR1407812365OtherNBMC NPI NUMBER-GROUP
OR0577260001Medicare NSC