Healthcare Provider's Profile
Full Name | |
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Type | Facility |
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Speciality | Ophthalmology |
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Location | 825 Se Bishop Blvd Ste 110, Pullman, Washington |
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Accepts Medicare Assignments | Does not participate in Medicare Program. The facility may not accept medicare assignment. |
NPI Data:
- NPI Number: 1710048772
- Provider Enumeration Date: 12/13/2006
- Last Update Date: 09/20/2011
Medical Identifiers
Medical identifiers for
such as npi, medicare ID, medicare PIN, medicaid, etc.
Identifier | Type | State | Issuer |
1710048772 | NPI | - | NPPES |
000010006387 | Other | | REGENCE BLUE SHIELD |
805350600 | Medicaid | ID | |
8927759 | Other | WA | CRIME VICTIMS |
85977 | Other | ID | BLUE CROSS |
0123143 | Other | WA | LABOR & IND |
24509 | Other | | GROUP HEALTH |
7088859 | Medicaid | WA | |
Medical Taxonomies and Licenses
Taxonomy | Type | License (State) | Status |
152W00000X | Optometrist | OD00003976 (Washington) | Secondary |
156FC0801X | Technician/technologist - Contact Lens Fitter | 601269693 (Washington) | Secondary |
156FX1800X | Technician/technologist - Optician | 601269693 (Washington) | Secondary |
207W00000X | Ophthalmology | MD00014109 (Washington) | Primary |
Medicare Part D Prescriber Enrollment
Any physician or other eligible professional who prescribes Part D drugs must either enroll in the Medicare program or opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans. is NOT enrolled with medicare and thus cannot prescribe medicare part D drugs to patients with medicare part D benefits.
Mailing Address and Practice Location
Mailing Address | Practice Location Address |
500 Port Dr, Clarkston, WA 99403-1835 Ph: (509) 758-8811 | 825 Se Bishop Blvd Ste 110, Pullman, WA 99163-5517 Ph: (509) 334-1661 |
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