Provider Demographics
NPI:1992722698
Name:SEROUSSI, RICHARD E (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:SEROUSSI
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 1:3213 EASTLAKE AVE E
Mailing Address - Street 2:SUITE A
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3826
Mailing Address - Country:US
Mailing Address - Phone:206-861-8200
Mailing Address - Fax:206-324-1178
Practice Address - Street 1:3213 EASTLAKE AVE E
Practice Address - Street 2:SUITE A
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3826
Practice Address - Country:US
Practice Address - Phone:206-861-8200
Practice Address - Fax:206-324-1178
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00031281208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA158738OtherLABOR & INDUSTRIES
WA9006SEOtherREGENCE RIDER NUMBER
WA8179723Medicaid
WA8179723Medicaid