Individual
THOMAS MODAD SOEPRONO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1959 NE PACIFIC ST, BOX 356560, SEATTLE, WA 98195-0001
(206) 598-6195
Mailing address
PO BOX 50095, SEATTLE, WA 98145-5095
(206) 520-5700
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
MD60475121
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1245559467
—
WA
Enumeration date
05/27/2010
Last updated
08/13/2015
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