Provider Demographics
NPI:1619974771
Name:SUTRO, JEFFREY BERNARD (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:BERNARD
Last Name:SUTRO
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 1:5017 196TH ST SW
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6123
Mailing Address - Country:US
Mailing Address - Phone:425-778-1588
Mailing Address - Fax:425-778-2523
Practice Address - Street 1:5017 196TH ST SW
Practice Address - Street 2:SUITE 204
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6123
Practice Address - Country:US
Practice Address - Phone:425-778-1588
Practice Address - Fax:425-778-2523
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1909TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2011963Medicaid
WAG115000261Medicare PIN
WA2011963Medicaid