Provider Demographics
NPI:1548610066
Name:IGBINOBA, BRETT E (OD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:E
Last Name:IGBINOBA
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 1:4330 MITCHELL WAY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9175
Practice Address - Country:US
Practice Address - Phone:360-738-6860
Practice Address - Fax:360-738-6853
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60601607152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2062225Medicaid