Healthcare Provider Details

I. General information

NPI: 1528337540
Provider Name (Legal Business Name): BERNARD VAUGHAN STEWART LDO-LICENSED DISPENS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2011
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY
SEATTLE WA
98122
US

IV. Provider business mailing address

801 BROADWAY - FIRST FLOOR STEWART OPTICAL SERVICES
SEATTLE WA
98122
US

V. Phone/Fax

Practice location:
  • Phone: 360-668-5228
  • Fax: 360-668-4120
Mailing address:
  • Phone: 360-668-5228
  • Fax: 360-668-4120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDO00000558
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: