1508050337 NPI number — BRIAN ARTHUR ARVIDSON I O.D

Table of content: BRIAN ARTHUR ARVIDSON I O.D (NPI 1508050337)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508050337 NPI number — BRIAN ARTHUR ARVIDSON I O.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ARVIDSON
Provider First Name:
BRIAN
Provider Middle Name:
ARTHUR
Provider Name Prefix Text:
Provider Name Suffix Text:
I
Provider Credential Text:
O.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508050337
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1506
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEHALIS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98532-0409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-242-3008
Provider Business Mailing Address Fax Number:
360-807-7687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2517 NE KRESKY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEHALIS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98532-2409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-748-8632
Provider Business Practice Location Address Fax Number:
360-748-3869
Provider Enumeration Date:
09/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  ATI3220 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: ODP-100229 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 3220 ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OD60119604 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: R159615 . This is a "MEDICARE OR" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 00773081 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 2012795 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 274666 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: G8900939 . This is a "MEDICARE WA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1594538 . This is a "MEDICARE ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com