Provider Demographics
NPI:1396748174
Name:HUDDLESTON, JAY L (OD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:L
Last Name:HUDDLESTON
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 1:1110 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-2104
Mailing Address - Country:US
Mailing Address - Phone:360-293-9312
Mailing Address - Fax:360-299-3937
Practice Address - Street 1:1110 12TH ST
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-2104
Practice Address - Country:US
Practice Address - Phone:360-293-9312
Practice Address - Fax:360-299-3937
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001311152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2083202Medicaid
911364148OtherEIN
WA2083202Medicaid
WAT029000Medicare UPIN
WAG8864678Medicare PIN