Provider Demographics
NPI:1194770164
Name:IYENGAR, JAISIMHA K (MD)
Entity type:Individual
Prefix:
First Name:JAISIMHA
Middle Name:K
Last Name:IYENGAR
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 111750
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98411-1750
Mailing Address - Country:US
Mailing Address - Phone:253-627-2666
Mailing Address - Fax:253-627-8661
Practice Address - Street 1:1818 S UNION AVE
Practice Address - Street 2:STE 1A
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1953
Practice Address - Country:US
Practice Address - Phone:253-627-2666
Practice Address - Fax:253-627-8661
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036006208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAF61871Medicare UPIN
WAGAB25892Medicare ID - Type Unspecified