Provider Demographics
NPI:1316027048
Name:CORLISS, KENNETH J (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:J
Last Name:CORLISS
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:PO BOX 1266
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0237
Mailing Address - Country:US
Mailing Address - Phone:253-845-0585
Mailing Address - Fax:253-845-1939
Practice Address - Street 1:312 4TH ST SE
Practice Address - Street 2:UNIT A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3269
Practice Address - Country:US
Practice Address - Phone:253-845-0585
Practice Address - Fax:253-845-1939
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD915152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2211704Medicaid
WA0016684OtherL & I
T02682Medicare UPIN
WA2211704Medicaid