Provider Demographics
NPI:1285717215
Name:KRIVOSHA, RONALD S (DPM)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:S
Last Name:KRIVOSHA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MADISON ST
Mailing Address - Street 2:SUITE 1120
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1306
Mailing Address - Country:US
Mailing Address - Phone:206-447-0302
Mailing Address - Fax:206-682-5951
Practice Address - Street 1:1101 MADISON STREET
Practice Address - Street 2:SUITE 1120
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2461
Practice Address - Country:US
Practice Address - Phone:206-447-0302
Practice Address - Fax:206-682-5951
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000177213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1010701Medicaid
WA0059835OtherLABOR AND INDUSTRIES
WA1086360001Medicare NSC
WATO1677Medicare UPIN
WAG000109840Medicare PIN