Provider Demographics
NPI:1407963770
Name:MAMIYA, REID I (OD)
Entity Type:Individual
Prefix:
First Name:REID
Middle Name:I
Last Name:MAMIYA
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 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:115 NEW VIEW CT NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5250
Practice Address - Country:US
Practice Address - Phone:360-252-1642
Practice Address - Fax:360-252-1646
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003835152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00178561OtherRAIL ROAD MEDICARE
ORR133052Medicare PIN
V03129Medicare UPIN
WAG8850520Medicare PIN
ID1594405Medicare PIN
WAP00178561OtherRAIL ROAD MEDICARE
MT000084548Medicare PIN
WAG8850521Medicare PIN
WAG8850522Medicare PIN
WAG8850524Medicare PIN
WAG8850525Medicare PIN