Provider Demographics
NPI:1851402085
Name:COMMON, KENNETH DOUGLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DOUGLAS
Last Name:COMMON
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 1:12804 SE 302ND ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98092-2172
Mailing Address - Country:US
Mailing Address - Phone:253-887-9174
Mailing Address - Fax:
Practice Address - Street 1:625 BLACK LAKE BLVD SW
Practice Address - Street 2:SUITE #110
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5066
Practice Address - Country:US
Practice Address - Phone:360-357-2544
Practice Address - Fax:360-357-6341
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1155TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist