Provider Demographics
NPI:1891783676
Name:SUSILASATE, WILBUR (OD)
Entity Type:Individual
Prefix:
First Name:WILBUR
Middle Name:
Last Name:SUSILASATE
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 1:7101 MARTIN LUTHER KING JR WAY S
Mailing Address - Street 2:# 209
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-3594
Mailing Address - Country:US
Mailing Address - Phone:206-722-2218
Mailing Address - Fax:206-722-2211
Practice Address - Street 1:7101 MARTIN LUTHER KING JR WAY S
Practice Address - Street 2:#209
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-3594
Practice Address - Country:US
Practice Address - Phone:206-722-2218
Practice Address - Fax:206-722-2211
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD 3608152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029262Medicaid
WA2029528Medicaid
WAG8805945Medicare PIN