Provider Demographics
NPI:1376695189
Name:SECREST, MICHAEL A (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:SECREST
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 1:301 S 320TH ST
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5200
Mailing Address - Country:US
Mailing Address - Phone:253-874-7557
Mailing Address - Fax:253-874-7557
Practice Address - Street 1:301 S 320TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5200
Practice Address - Country:US
Practice Address - Phone:253-874-7557
Practice Address - Fax:253-874-7557
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003346152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2022994Medicaid
WAGAB13605Medicare PIN
WAU66287Medicare UPIN
WA2022994Medicaid
WAGAB13609Medicare PIN
WAP00343309Medicare PIN