Provider Demographics
NPI:1124028782
Name:SYMONDS, GEORGE B
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:B
Last Name:SYMONDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-4308
Mailing Address - Country:US
Mailing Address - Phone:360-457-1161
Mailing Address - Fax:360-457-2806
Practice Address - Street 1:1122 E FRONT ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4308
Practice Address - Country:US
Practice Address - Phone:360-457-1161
Practice Address - Fax:360-457-2806
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001757152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2006096Medicaid
WAG000500197OtherMEDICARE ID-PIN
0D00001757OtherWA
0D00001757OtherWA
MS1156555OtherDEA
WA0219530001Medicare NSC