Provider Demographics
NPI:1306818513
Name:BACKONJA, MIROSLAV (MD)
Entity type:Individual
Prefix:
First Name:MIROSLAV
Middle Name:
Last Name:BACKONJA
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 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-520-5700
Mailing Address - Fax:
Practice Address - Street 1:4225 ROOSEVELT WAY NE FL 4
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-6099
Practice Address - Country:US
Practice Address - Phone:206-598-4282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD605274032084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1306818513Medicaid
WA8943994Medicare PIN