Provider Demographics
NPI:1194812404
Name:COVERDALE, CHARLES RONALD (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RONALD
Last Name:COVERDALE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6830 NE BOTHELL WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-3546
Mailing Address - Country:US
Mailing Address - Phone:425-485-3051
Mailing Address - Fax:425-482-2441
Practice Address - Street 1:6830 NE BOTHELL WAY
Practice Address - Street 2:SUITE B
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-3546
Practice Address - Country:US
Practice Address - Phone:425-485-3051
Practice Address - Fax:425-482-2441
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA895152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA912126732OtherTAX ID
WAT01569Medicare UPIN
WA6313780001Medicare NSC