Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 1877TX | WA |
NPI | 1003804014 |
---|---|
Provider Name | Dr. Tony D. Pool |
First Address | Edmonds, WA 98026-6971 |
Second Address | Edmonds, WA 98020-3162 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T90583 | (02) | WA |