Provider Demographics
NPI:1407929813
Name:LLEWELLYN, BRETT DAVID (OD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:DAVID
Last Name:LLEWELLYN
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 1:6813 19TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-6941
Mailing Address - Country:US
Mailing Address - Phone:206-367-5362
Mailing Address - Fax:
Practice Address - Street 1:342 15TH AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-5103
Practice Address - Country:US
Practice Address - Phone:206-625-9061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA3212TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2019024Medicaid
WA2019024Medicaid
G2170007774Medicare ID - Type Unspecified