Provider Demographics
NPI:1598042863
Name:JEFFREY S. NEVITT OD
Entity type:Organization
Organization Name:JEFFREY S. NEVITT OD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:NEVITT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-942-5501
Mailing Address - Street 1:500 WILLAPA PL
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98577-2507
Mailing Address - Country:US
Mailing Address - Phone:360-942-5501
Mailing Address - Fax:360-942-5849
Practice Address - Street 1:500 WILLAPA PL
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577-2507
Practice Address - Country:US
Practice Address - Phone:360-942-5501
Practice Address - Fax:360-942-5849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD 00001562152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0128360OtherLABOR & INDUSTRIES
WAN1523OtherPREMERA BLUE CROSS
WA1090708Medicaid
WAB00298624OtherTRICARE
WANE6969OtherREGENCE BLUE SHIELD
WAT60971Medicare UPIN
WAAB09204Medicare PIN
WA0128360OtherLABOR & INDUSTRIES