Provider Demographics
NPI:1104809995
Name:NAKAMOTO, AVA MINEKO (OD)
Entity type:Individual
Prefix:DR
First Name:AVA
Middle Name:MINEKO
Last Name:NAKAMOTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 S 293RD ST
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-3694
Mailing Address - Country:US
Mailing Address - Phone:253-946-4850
Mailing Address - Fax:253-838-0875
Practice Address - Street 1:32717 1ST AVE S
Practice Address - Street 2:SUITE 6
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5758
Practice Address - Country:US
Practice Address - Phone:253-838-5428
Practice Address - Fax:253-838-0875
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001560152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2027662Medicaid
WA2027662Medicaid
WAAB22702Medicare ID - Type Unspecified