Provider Demographics
NPI:1033191507
Name:CHURCH, WILLIAM STUART (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:STUART
Last Name:CHURCH
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 1:3700 COLBY AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4911
Mailing Address - Country:US
Mailing Address - Phone:425-252-3937
Mailing Address - Fax:425-259-3895
Practice Address - Street 1:3700 COLBY AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4911
Practice Address - Country:US
Practice Address - Phone:425-252-3937
Practice Address - Fax:425-259-3895
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA869TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2208908Medicaid
WAG001200125Medicare ID - Type Unspecified
WAT02961Medicare UPIN