Provider Demographics
NPI:1588619670
Name:CLAVADETSCHER, JOHN E (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:CLAVADETSCHER
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 1:21005 44TH AVE W
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-3584
Mailing Address - Country:US
Mailing Address - Phone:425-775-7144
Mailing Address - Fax:425-673-7885
Practice Address - Street 1:21005 44TH AVE W
Practice Address - Street 2:SUITE 102
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-3584
Practice Address - Country:US
Practice Address - Phone:425-775-7144
Practice Address - Fax:425-673-7885
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3280TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8026031Medicaid
WA8026031Medicaid
WAU72785Medicare UPIN