Provider Demographics
NPI:1316057201
Name:BERRY, C. SANFORD (OD)
Entity type:Individual
Prefix:DR
First Name:C.
Middle Name:SANFORD
Last Name:BERRY
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:PO BOX 2941
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-2941
Mailing Address - Country:US
Mailing Address - Phone:360-402-0019
Mailing Address - Fax:
Practice Address - Street 1:5500 LITTLEROCK RD SW
Practice Address - Street 2:COSTCO OPTICAL
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7363
Practice Address - Country:US
Practice Address - Phone:360-709-0878
Practice Address - Fax:360-709-0878
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001759152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU20853Medicare UPIN