Provider Demographics
NPI:1407302003
Name:BOTELHO, KORY (OD)
Entity Type:Individual
Prefix:
First Name:KORY
Middle Name:
Last Name:BOTELHO
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 1:411 STRANDER BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2959
Mailing Address - Country:US
Mailing Address - Phone:206-575-4396
Mailing Address - Fax:
Practice Address - Street 1:411 STRANDER BLVD STE 202
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2959
Practice Address - Country:US
Practice Address - Phone:206-575-4396
Practice Address - Fax:206-575-4396
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60660393152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist