Provider Demographics
NPI:1033103221
Name:FRAIRE, DOLORES MAE (OD)
Entity Type:Individual
Prefix:DR
First Name:DOLORES
Middle Name:MAE
Last Name:FRAIRE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DOLORES
Other - Middle Name:MAE
Other - Last Name:SCHMITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1192 E ISLAND LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-7824
Mailing Address - Country:US
Mailing Address - Phone:360-432-5829
Mailing Address - Fax:
Practice Address - Street 1:1635 OLYMPIC HWY N
Practice Address - Street 2:STE 102
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3065
Practice Address - Country:US
Practice Address - Phone:360-427-7553
Practice Address - Fax:360-426-2033
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3108152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB19883Medicaid
WAU83955Medicare UPIN
WAAB19883Medicaid