Provider Demographics
NPI:1528168432
Name:PODHAISKY, GARY M (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:PODHAISKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3900 S ZINTEL WAY
Mailing Address - Street 2:FL 2
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-5092
Mailing Address - Country:US
Mailing Address - Phone:509-942-3125
Mailing Address - Fax:509-585-8173
Practice Address - Street 1:3900 ZINTEL WAY
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99338
Practice Address - Country:US
Practice Address - Phone:509-942-3125
Practice Address - Fax:509-783-2167
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2021-06-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NV9069208000000X
WAMD00048590208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8493496Medicaid
WA8867493Medicare PIN