Basic Information
| Provider Information | |||||||||
| NPI: | 1477812873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | URDANETA-MONCADA | ||||||||
| FirstName: | ALFONSO | ||||||||
| MiddleName: | RICARDO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631501 | ||||||||
| 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: | 05/07/2012 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 116005 | AK | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | MD60665935 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 116005 | AK | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | M-13632 | ID | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | MD60665935 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0700X | M-13632 | ID | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 2046104 | 05 | WA | MEDICAID | 1477812873 | 05 | ID | MEDICAID |