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ESRAVILA ARIYA WIBISONO MD
NPI 1972233708
Internal Medicine in Bonney Lake, WA

Active since June 14, 2022PECOS EnrolledAccepts Medicare Assignment
10004 204TH AVE E STE 2200, BONNEY LAKE, WA 98391(253) 447-3300 Get Directions Write a Review

NPPES record last updated: July 31, 2025. Verified against the NPPES registry weekly; last sync: August 09, 2026.

About Esravila Ariya Wibisono Md NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

ESRAVILA ARIYA WIBISONO MD (NPI 1972233708) is an individual internal medicine provider in Bonney Lake, Washington, licensed in Washington (MD61603415) and active in the NPI registry since June 2022. He is enrolled in Medicare PECOS, is affiliated with Multicare Good Samaritan Hospital, and maintains a secondary practice location in Waterbury.

NPPES Registry Identity

NPI1972233708
Entity TypeIndividualMale
Primary Taxonomy207R00000X
Provider Legal NameESRAVILA ARIYA WIBISONOCredential: MD
Location Address10004 204TH AVE E STE 2200Bonney Lake, WA 98391-6537
Mailing Address10004 204th Ave E Ste 2200Bonney Lake, WA 98391-6537 · (253) 447-3300
Phone(253) 447-3300
Sole ProprietorNo
Medical School CMSOtherGraduated 2018
Enumeration DateJune 14, 2022
Last NPPES UpdateJuly 31, 2025
NPPES CertifiedJuly 31, 2025
✔ NPI 1972233708 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses 2

★ Primary SpecialtyInternal MedicineAllopathic & Osteopathic Physicians
Taxonomy Code207R00000X
License✔ Licensed in WA · MD61603415
Definition
A physician who provides long-term, comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults and the elderly. Internists are trained in the diagnosis and treatment of cancer, infections and diseases affecting the heart, blood, kidneys, joints and digestive, respiratory and vascular systems. They are also trained in the essentials of primary care internal medicine, which incorporates an understanding of disease prevention, wellness, substance abuse, mental health and effective treatment of common problems of the eyes, ears, skin, nervous system and reproductive organs.
Also ListedStudent in an Organized Health Care Education/Training ProgramTaxonomy 390200000X · License 06-0646844 (CT)
10004 204TH AVE E STE 2200, Bonney Lake, WA 98391
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Secondary Practice Location 1

Location 156 Franklin St Ste 1Waterbury, CT 06706-1281 · Phone (203) 709-8685 · Fax (203) 709-3518

Accepted Insurance

The full list of accepted plans is on the Insurance tab. Issuers include Premera Blue Cross Blue Shield of Alaska, Providence Health Plan.Insurance ›

Medicare Participation & PECOS CMS

Medicare enrollment, assignment, and ordering and referring status from the CMS PECOS system.

Medicare Enrollment Status

✔

Enrolled in Medicare and accepts Medicare assignment

Esravila Ariya Wibisono Md is registered in PECOS and agrees to accept the Medicare-approved amount as full payment. Medicare patients are not billed beyond the standard deductible and coinsurance.

PECOS PAC ID1254712839
PECOS Enrollment IDI20250909004774
Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment✔ Home Health Agency✔ Power Mobility DevicesPer the CMS Ordering and Referring file. Eligibility means Medicare pays claims that this provider orders or refers for these categories.

Hospital Affiliations CMS Care Compare 2

Hospitals where this provider delivers care, identified from recent Medicare claims and place-of-service records.

Multicare Good Samaritan Hospital

Acute Care Hospitals · Puyallup, WA
1/5 CMS rating
OwnershipVoluntary non-profit - Private
CMS Certification Number500079
Location401 15th Avenue SEPuyallup, WA 98372 · Pierce County
Emergency services Birthing friendly

Tacoma General Allenmore Hospital

Acute Care Hospitals · Tacoma, WA
2/5 CMS rating
OwnershipVoluntary non-profit - Private
CMS Certification Number500129
Location315 S Mlk Jr WayTacoma, WA 98405 · Pierce County
Emergency services Birthing friendly

Physician Visit Costs CMS claims · ZIP area

Typical Medicare office-visit costs in the 98391 ZIP code area, from fee-for-service claims. These are area statistics, not this provider’s prices; actual charges vary by service and coverage.

New Patient
$130.99 typical visit price
range $57.27 – $172.80
Typical copayment $32.74 (range $14.31 – $43.20)
Most-billed visit code 99204
Established Patient
$100.78 typical visit price
range $18.56 – $141.11
Typical copayment $25.19 (range $4.64 – $35.27)
Most-billed visit code 99214
Amounts reflect what Medicare beneficiaries in this ZIP area are typically charged for office visits. Patients with other coverage should check their individual plans.

Other Providers at the Same Location NPPES

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

SAYDEE HOMOLKA PA-C
Physician Assistant
10004 204TH AVE E STE 2200
BONNEY LAKE, WA 98391
Pierce County (253) 447-3300

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Esravila Wibisono's NPI number?

The NPI number for Esravila Wibisono is 1972233708. It was assigned to this individual provider in the NPPES registry on June 14, 2022.

Where is Esravila Wibisono located?

Esravila Wibisono practices at 10004 204th Ave E Ste 2200, Bonney Lake, WA 98391. The listed phone number is (253) 447-3300.

What is Esravila Wibisono's specialty?

The primary specialty registered for this NPI is Internal Medicine with taxonomy code 207R00000X.

Is Esravila Wibisono enrolled in Medicare?

Yes. Esravila Wibisono is registered in the Medicare PECOS system and accepts Medicare assignment, which means accepting the Medicare-approved amount as payment in full for covered services.

What insurance does Esravila Wibisono accept?

Health plans from Premera Blue Cross Blue Shield of Alaska and Providence Health Plan list Esravila Wibisono as in-network in at least one marketplace plan. Coverage varies by plan and year; verify with the insurer or the provider before a visit.

Is Esravila Wibisono affiliated with any hospitals?

According to CMS data, Esravila Wibisono is affiliated with Multicare Good Samaritan Hospital and Tacoma General Allenmore Hospital.

When was this NPI record last updated?

The NPPES record for Esravila Wibisono was last updated on July 31, 2025. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 12 months ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.