Basic Information
| Provider Information | |||||||||
| NPI: | 1861631459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUNIDJA | ||||||||
| FirstName: | ADITYA | ||||||||
| MiddleName: | PANDU | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1535 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984011535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Practice Location | |||||||||
| Address1: | 1304 FAWCETT AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984021911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2009 | ||||||||
| LastUpdateDate: | 02/09/2015 | ||||||||
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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 | MD60082442 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 174400000X | 235938 | MA | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | G8883319 | 01 | WA | PTAN-TRA KING CO | OTHER | 2001567 | 05 | WA | MEDICAID | G8882744 | 01 | WA | PTAN-TRA PIERCE CO | OTHER | 0252135 | 01 | WA | LABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST | OTHER | G8883121 | 01 | WA | PTAN-MIO1 | OTHER | G8882901 | 01 | WA | PTAN-UAOM | OTHER | R174972 | 01 | WA | PTAN-PENDLETON, OREGON | OTHER |