Provider Demographics
NPI:1699706986
Name:WATTERS, KEVIN LYNN (OD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:LYNN
Last Name:WATTERS
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 1:101 NW 12TH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-9141
Mailing Address - Country:US
Mailing Address - Phone:360-687-0755
Mailing Address - Fax:360-666-8664
Practice Address - Street 1:101 NW 12TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604-9141
Practice Address - Country:US
Practice Address - Phone:360-687-0755
Practice Address - Fax:360-666-8664
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3123152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2016855Medicaid
U51595Medicare UPIN
WAG115000334Medicare PIN