Provider Demographics
NPI:1306880638
Name:LOHAVANICHBUTR, KAMOL (MD)
Entity type:Individual
Prefix:
First Name:KAMOL
Middle Name:
Last Name:LOHAVANICHBUTR
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 1:1400 E. KINCAID ST.
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:307 S 13TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4100
Practice Address - Country:US
Practice Address - Phone:360-336-9757
Practice Address - Fax:360-814-5237
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036595207RI0011X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8417024Medicaid
WA8417024Medicaid
WAH34382Medicare UPIN
WAG8895502Medicare PIN
WAG8895502Medicare PIN