Provider Demographics
NPI:1588699078
Name:WODTLI, GERALD L (OD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:L
Last Name:WODTLI
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 1:1906 N 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-3393
Mailing Address - Country:US
Mailing Address - Phone:509-547-8409
Mailing Address - Fax:509-544-7875
Practice Address - Street 1:1906 N 20TH AVE
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-3393
Practice Address - Country:US
Practice Address - Phone:509-547-8409
Practice Address - Fax:509-544-7875
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL1070152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2027696Medicaid
WA0070297OtherDEPT OF LABOR & INDUSTRY
WA410049226OtherRAILROAD MEDICARE
WA4613160001Medicare NSC
WA0070297OtherDEPT OF LABOR & INDUSTRY
WA2027696Medicaid