Provider Demographics
NPI:1508964180
Name:PELLOW, WILLIAM A X (OD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:A
Last Name:PELLOW
Suffix:X
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 409
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:WA
Mailing Address - Zip Code:99166-0409
Mailing Address - Country:US
Mailing Address - Phone:509-775-3800
Mailing Address - Fax:509-775-3994
Practice Address - Street 1:90 N CLARK AVE
Practice Address - Street 2:UNIT 3
Practice Address - City:REPUBLIC
Practice Address - State:WA
Practice Address - Zip Code:99166-5024
Practice Address - Country:US
Practice Address - Phone:509-775-3800
Practice Address - Fax:509-775-3994
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1669TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2001386Medicaid
WAG00030125Medicare PIN
WA0777020001Medicare NSC
WA2001386Medicaid