Basic Information
| Provider Information | |||||||||
| NPI: | 1144364605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUSANTO | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631374 | ||||||||
| Practice Location | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2007 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 17687 | MN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD60083485 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | S-7900 | AK | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | M-12378 | ID | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | MD60083485 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 1144364605 | 05 | ID | MEDICAID | 263299 | 01 | WA | LNI | OTHER | 1584895 | 05 | AK | MEDICAID | 263302 | 01 | WA | LNI | OTHER | 263305 | 01 | WA | LNI | OTHER | 2007663 | 05 | WA | MEDICAID |