Healthcare Provider Details

I. General information

NPI: 1386096220
Provider Name (Legal Business Name): BRITTNEY MELISSA GEWOLB O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2016
Last Update Date: 07/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5821 S SPRAGUE CT # 102
TACOMA WA
98409-6903
US

IV. Provider business mailing address

38 LEWIS LN
SYOSSET NY
11791-3928
US

V. Phone/Fax

Practice location:
  • Phone: 253-396-4257
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number60661206
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: