Provider Demographics
NPI:1992798805
Name:PATTILLO, MICHAEL J (MD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:PATTILLO
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 1:550 GAGE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9532
Mailing Address - Country:US
Mailing Address - Phone:509-946-4611
Mailing Address - Fax:509-627-2983
Practice Address - Street 1:945 GOETHALS DR STE 300
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3552
Practice Address - Country:US
Practice Address - Phone:509-943-3196
Practice Address - Fax:509-946-0455
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041086208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA159331OtherLABOR & INDUSTRY
WA8314833Medicaid
WA159331OtherLABOR & INDUSTRY
WA8314833Medicaid