Basic Information
| Provider Information | |||||||||
| NPI: | 1740347947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAVILALA | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | SHANTA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50095 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981455095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065436420 | ||||||||
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| Practice Location | |||||||||
| Address1: | HARBORVIEW MEDICAL CENTER | ||||||||
| Address2: | 325 9TH AVE | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067313000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 02/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD00031742 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 208000000X | MD00031742 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3186 | 01 | INTERNAL ID-MOTOR VEHICLE ID | OTHER | 0232118 | 01 | WA | L&I | OTHER | 050057264 | 01 | WA | RAILROAD MEDICARE | OTHER | 1740347947 | 05 | WA | MEDICAID |