Provider Demographics
NPI:1699038661
Name:KEO, VUTHA (OD)
Entity type:Individual
Prefix:DR
First Name:VUTHA
Middle Name:
Last Name:KEO
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 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-339-5435
Mailing Address - Fax:425-317-3932
Practice Address - Street 1:3901 HOYT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4918
Practice Address - Country:US
Practice Address - Phone:425-339-5435
Practice Address - Fax:425-317-3932
Is Sole Proprietor?:No
Enumeration Date:2012-06-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60324660152W00000X
CA14459152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2057670Medicaid
WA2057670Medicaid