Provider Demographics
NPI:1699760744
Name:SCARBROUGH, KERRI W (OD)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:W
Last Name:SCARBROUGH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17320 135TH AVE NE STE D
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-8565
Mailing Address - Country:US
Mailing Address - Phone:425-398-1862
Mailing Address - Fax:
Practice Address - Street 1:17320 135TH AVE NE STE D
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-8565
Practice Address - Country:US
Practice Address - Phone:425-398-1862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA1675TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023877Medicaid
WAG8872105Medicare PIN
WAU22594Medicare UPIN