William A Pellow X, OD – Optometrist in Republic, WA

Key facts

NPI: 1508964180
Entity type: Individual (NPI type 1)
Primary specialty: Optometrist 152W00000X
License: 1669TX (WA)
Practice address: 90 N Clark Ave
Unit 3
Republic, WA 99166-5024
Phone: (509) 775-3800
Fax: (509) 775-3994
NPI assigned: Sep 20, 2006
Sex: Male
Sole proprietor: Yes

Medicare participation

Medicare fee-for-service enrollment: Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD): Yes

State licenses

License	State	Type	Specialty
1669TX	WA	MD	Optometrist

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Optometrist	152W00000X	1669TX	WA	Yes

Addresses

Primary practice location

90 N Clark Ave
Unit 3
Republic, WA 99166-5024

Mailing address

PO Box 409
Republic, WA 99166-0409
Phone (509) 775-3800

Other identifiers

Identifier	Type	State	Issuer
2001386	Medicaid	WA

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Oct 2, 2012.

{
    "created_epoch": "1158710400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1349136000000",
    "number": "1508964180",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 409",
            "city": "REPUBLIC",
            "state": "WA",
            "postal_code": "991660409",
            "telephone_number": "509-775-3800",
            "fax_number": "509-775-3994"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "90 N CLARK AVE",
            "address_2": "UNIT 3",
            "city": "REPUBLIC",
            "state": "WA",
            "postal_code": "991665024",
            "telephone_number": "509-775-3800",
            "fax_number": "509-775-3994"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PELLOW",
        "first_name": "WILLIAM",
        "middle_name": "A",
        "name_prefix": "Dr.",
        "name_suffix": "X",
        "credential": "OD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-09-20",
        "last_updated": "2012-10-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "WA",
            "license": "1669TX",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2001386",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Republic, WA

All providers in Republic, WA · Optometrist in Washington

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 2, 2012. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.