Provider Demographics
NPI:1508003252
Name:DAVID J PEDIGO OD PS
Entity Type:Organization
Organization Name:DAVID J PEDIGO OD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEDIGO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-645-1548
Mailing Address - Street 1:222 SW EVERETT MALL WAY
Mailing Address - Street 2:STE 11
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-2780
Mailing Address - Country:US
Mailing Address - Phone:425-645-1548
Mailing Address - Fax:425-328-1254
Practice Address - Street 1:1515 E TUDOR RD
Practice Address - Street 2:STE 5
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-1035
Practice Address - Country:US
Practice Address - Phone:425-645-1548
Practice Address - Fax:425-328-1254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-17
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK277152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1023246Medicaid