Provider Demographics
NPI:1689660128
Name:WEBSTER, GREGORY A (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:WEBSTER
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 729
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-0062
Mailing Address - Country:US
Mailing Address - Phone:360-577-0606
Mailing Address - Fax:360-636-2986
Practice Address - Street 1:1704 ALLEN ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-4907
Practice Address - Country:US
Practice Address - Phone:360-577-0606
Practice Address - Fax:360-636-2986
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1025152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1016328Medicaid
WA0224200001Medicare NSC
WA41005107Medicare PIN
WA1016328Medicaid
WAT02670Medicare UPIN