Provider Demographics
NPI:1194879700
Name:BOBOTH, FRED C (OD, PS)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:C
Last Name:BOBOTH
Suffix:
Gender:M
Credentials:OD, PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N EUCLID RD
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98930-9407
Mailing Address - Country:US
Mailing Address - Phone:509-882-2650
Mailing Address - Fax:509-882-4225
Practice Address - Street 1:403 N EUCLID RD
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-9407
Practice Address - Country:US
Practice Address - Phone:509-882-2650
Practice Address - Fax:509-882-4225
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1634TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0317360001OtherDME REGION D SUPPLIER NO
WAG8902905OtherCHAMPUS ID NO REGION WEST
WA71549OtherLABOR AND INDUSTRIES
WA911936651OtherGROUP HEALTH NORTHWEST
WABO4392OtherBLUE CROSS BLUE SHIELD NO
WA911936651OtherPREMERA BLUE CROSS
WA010062119OtherMEDICARE RAILROAD
WA2021554Medicaid
WA911936651OtherPREMERA BLUE CROSS
WA2021554Medicaid