1508964180 NPI number — DR. WILLIAM A PELLOW X OD

Table of content: DR. WILLIAM A PELLOW X OD (NPI 1508964180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508964180 NPI number — DR. WILLIAM A PELLOW X OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELLOW
Provider First Name:
WILLIAM
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
X
Provider Credential Text:
OD
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:
1508964180
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 409
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REPUBLIC
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99166-0409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-775-3800
Provider Business Mailing Address Fax Number:
509-775-3994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 N CLARK AVE
Provider Second Line Business Practice Location Address:
UNIT 3
Provider Business Practice Location Address City Name:
REPUBLIC
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99166-5024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-775-3800
Provider Business Practice Location Address Fax Number:
509-775-3994
Provider Enumeration Date:
09/20/2006

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:  1669TX , 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: 2001386 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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