Provider Demographics
NPI:1942388236
Name:BORGHOLTHAUS, SCOTT EDWARD (OD OPTOMETRIST)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:EDWARD
Last Name:BORGHOLTHAUS
Suffix:
Gender:M
Credentials:OD OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1867 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-1967
Mailing Address - Country:US
Mailing Address - Phone:509-235-2010
Mailing Address - Fax:509-235-2011
Practice Address - Street 1:1867 1ST ST
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:WA
Practice Address - Zip Code:99004-1967
Practice Address - Country:US
Practice Address - Phone:509-452-3937
Practice Address - Fax:509-453-6567
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0736152W00000X
OR1812152W00000X
WA3218152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA815580OtherREGENCE BLUE SHIELD
WA2028124Medicaid
P00271493OtherPALMETTO GBA RAILROAD MED
GAB01150Medicare ID - Type Unspecified
WA815580OtherREGENCE BLUE SHIELD