Provider Demographics
NPI:1932253697
Name:ITO, BRIAN M (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:ITO
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 1:11511 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-8578
Mailing Address - Country:US
Mailing Address - Phone:425-502-3000
Mailing Address - Fax:
Practice Address - Street 1:11511 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-8578
Practice Address - Country:US
Practice Address - Phone:425-502-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020167207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8107179Medicaid
WAA14917Medicare UPIN
WA8107179Medicaid