Provider Demographics
NPI:1598040644
Name:BOBOTH, COLE
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:
Last Name:BOBOTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98930-9407
Mailing Address - Country:US
Mailing Address - Phone:509-882-2650
Mailing Address - Fax:509-882-4225
Practice Address - Street 1:403 N EUCLID ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:WA
Practice Address - Zip Code:98930-9407
Practice Address - Country:US
Practice Address - Phone:509-882-2650
Practice Address - Fax:509-882-4225
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60469574152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-1936651OtherVISION SERVICE PLAN
WA2021554Medicaid