Provider Demographics
NPI:1063409134
Name:NEVITT, JEFFREY S (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:NEVITT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WILLAPA PLACE
Mailing Address - Street 2:PACIFIC EYE CLINIC
Mailing Address - City:RAYMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98577
Mailing Address - Country:US
Mailing Address - Phone:360-942-5501
Mailing Address - Fax:360-942-5849
Practice Address - Street 1:500 WILLAPA PLACE
Practice Address - Street 2:PACIFIC EYE CLINIC
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577
Practice Address - Country:US
Practice Address - Phone:360-942-5501
Practice Address - Fax:360-942-5849
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1562152W00000X
WAMN1144257152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
N1523OtherPBX
NE6969OtherRBS
WA2022358Medicaid
B00298624OtherTRICARE
WA002OtherNBN
128360OtherL AND I
B00298624OtherTRICARE
T60971Medicare UPIN
WAAB09204Medicare ID - Type UnspecifiedREGION D
WA1292480001Medicare NSC