Provider Demographics
NPI:1679518161
Name:ROS, SAPHOL (OD)
Entity type:Individual
Prefix:DR
First Name:SAPHOL
Middle Name:
Last Name:ROS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17801 108TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6420
Mailing Address - Country:US
Mailing Address - Phone:425-271-9211
Mailing Address - Fax:425-271-9214
Practice Address - Street 1:17801 108TH AVE SE
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6420
Practice Address - Country:US
Practice Address - Phone:425-271-9211
Practice Address - Fax:425-271-9214
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001898152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU41124Medicare UPIN