Provider Demographics
NPI:1194780361
Name:WALDO, BENJAMIN LEE (OD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:LEE
Last Name:WALDO
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 1:14201 NE 20TH AVE, STE A102
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-6411
Mailing Address - Country:US
Mailing Address - Phone:360-574-6030
Mailing Address - Fax:360-574-4116
Practice Address - Street 1:14201 NE 20TH AVE STE A102
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-6411
Practice Address - Country:US
Practice Address - Phone:360-574-6030
Practice Address - Fax:360-574-4116
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60022188OD152W00000X
WA60022188 OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV00112571000Medicaid
WV0150205000Medicaid
WV0150205000Medicaid
WVVO4606Medicare UPIN
WV00112571000Medicaid