Provider Demographics
NPI:1699874420
Name:STODDARD, JOHN C (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:STODDARD
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 1126
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0169
Mailing Address - Country:US
Mailing Address - Phone:360-748-9228
Mailing Address - Fax:360-748-4617
Practice Address - Street 1:1179 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3427
Practice Address - Country:US
Practice Address - Phone:360-748-9228
Practice Address - Fax:360-748-4617
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001851152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAHE7836OtherREGENCE CLINIC NUMBER
WAST3361OtherREGENCE JCSTODDARD
WA0056033OtherL&I JCSTODDARD ONLY
WA0036580OtherL&I CLINIC GROUP
WA2046506Medicaid
WA2011716Medicaid
WAST3361OtherREGENCE JCSTODDARD
WA2046506Medicaid
WA2011716Medicaid
WA0036580OtherL&I CLINIC GROUP