Provider Demographics
NPI:1184662132
Name:OGLE, SAMUEL GARRETT (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:GARRETT
Last Name:OGLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 N 13TH LOOP RD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-2166
Mailing Address - Country:US
Mailing Address - Phone:360-426-4142
Mailing Address - Fax:360-427-5772
Practice Address - Street 1:1710 N 13TH LOOP RD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2166
Practice Address - Country:US
Practice Address - Phone:360-426-4142
Practice Address - Fax:360-427-5772
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032175208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA020031031OtherRRM
WA46982OtherL&I
WA8161127Medicaid
WAOG8275OtherREGENCE
WA020031031OtherRRM
WAF92801Medicare UPIN
WA115000387Medicare PIN