MEDICARE: DR. CHARLES SRISATAYASUNTON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OD60658151	WA
2	152W00000X	Optometrist	3641ATI	OR

General Provider Information

NPI Number	:	1265784508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES SRISATAYASUNTON O.D.

Provider Business Mailing Address
First Line	:	19400 108TH AVE SE STE 202
Second Line	:
City	:	KENT
State	:	WA
Zip	:	98031-0108
Country	:	US
Telephone Number	:	253-852-2120
Fax Number	:

Provider Business Practice Location Address
First Line	:	19400 108TH AVE SE STE 202
Second Line	:
City	:	KENT
State	:	WA
Zip	:	98031-0108
Country	:	US
Telephone Number	:	253-852-2120
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2012
Last Update Date	:	01/05/2021

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Directions to “ DR. CHARLES SRISATAYASUNTON O.D.” Practice Location

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