Healthcare Provider Details

I. General information

NPI: 1902158249
Provider Name (Legal Business Name): VLADIMIR STOVBYR OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10024 SE 240TH ST SUITE 220
KENT WA
98031-5124
US

IV. Provider business mailing address

10024 SE 240TH ST SUITE 220
KENT WA
98031-5124
US

V. Phone/Fax

Practice location:
  • Phone: 253-852-5440
  • Fax: 253-852-0272
Mailing address:
  • Phone: 253-852-5440
  • Fax: 253-852-0272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD60568332
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: