Provider Demographics
NPI:1699896167
Name:BOUTERSE, CHAD RYAN (DO)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:RYAN
Last Name:BOUTERSE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:500 PORT DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1835
Mailing Address - Country:US
Mailing Address - Phone:509-758-8811
Mailing Address - Fax:509-751-1188
Practice Address - Street 1:500 PORT DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-1835
Practice Address - Country:US
Practice Address - Phone:509-758-8811
Practice Address - Fax:509-751-1188
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016467207W00000X
WAOP60127012207W00000X
IDO 570207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0080BOOtherASURIS - CLARKSTON
1699896167OtherFEDERAL BLUE CROSS
ID808567101OtherMEDICAID - PULLMAN
WA258958OtherWASHINGTON LABOR & INDUSTRY
ID808567100OtherMEDICAID - CLARKSTON
1699896167OtherPREMERA BLUE CROSS
0081BOOtherASURIS - PULLMAN
IDO 0570OtherSTATE LICENSE
WAOP60127012OtherSTATE LICENSE
1699896167OtherREGENCE BLUE SHIELD
1699896167OtherBLUE CROSS OF IDAHO
WA8564387Medicaid
WA258958OtherWASHINGTON LABOR & INDUSTRY