Provider Demographics
NPI:1588721815
Name:DORN, TED L (OD)
Entity type:Individual
Prefix:
First Name:TED
Middle Name:L
Last Name:DORN
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 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:10516 SILVERDALE WAY NW
Practice Address - Street 2:SUITE 104
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8745
Practice Address - Country:US
Practice Address - Phone:360-692-3950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00000917152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2031714Medicaid
WAP00265201Medicare PIN
WAG8872298Medicare PIN
WA2031714Medicaid
WAG000135881Medicare PIN
WAGAB20031Medicare PIN
WAGAB20032Medicare PIN
WAGAB20034Medicare PIN
WAP00160311Medicare PIN