Basic Information
Provider Information | |||||||||
NPI: | 1033427026 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EYE PHYSICIANS OF OLYMPIA INC PS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CLARUS EYE CENTRE DUPONT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 STATION DR | ||||||||
Address2: | SUITE 150 | ||||||||
City: | DUPONT | ||||||||
State: | WA | ||||||||
PostalCode: | 983279804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2539122020 | ||||||||
FaxNumber: | 2535791153 | ||||||||
Practice Location | |||||||||
Address1: | 1200 STATION DR | ||||||||
Address2: | SUITE 150 | ||||||||
City: | DUPONT | ||||||||
State: | WA | ||||||||
PostalCode: | 983279804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2539122020 | ||||||||
FaxNumber: | 2535791153 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2010 | ||||||||
LastUpdateDate: | 09/23/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BALDWIN | ||||||||
AuthorizedOfficialFirstName: | PATRICIA | ||||||||
AuthorizedOfficialMiddleName: | JOYCE | ||||||||
AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 3609234330 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | 00004005 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
No ID Information.