Provider Demographics
NPI:1003017476
Name:FRED C. BOBOTH O.D., P.S.
Entity Type:Organization
Organization Name:FRED C. BOBOTH O.D., P.S.
Other - Org Name:BOBOTH VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOBOTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-882-2650
Mailing Address - Street 1:403 N EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98930-9407
Mailing Address - Country:US
Mailing Address - Phone:509-882-2650
Mailing Address - Fax:509-882-4225
Practice Address - Street 1:403 N EUCLID ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930
Practice Address - Country:US
Practice Address - Phone:509-882-2650
Practice Address - Fax:509-882-4225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1634TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0317360001Medicare NSC