Provider Demographics
NPI:1184770398
Name:COURTNEY, HERBERT WESLEY JR (OD)
Entity type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:WESLEY
Last Name:COURTNEY
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14841 179TH AVE SE
Mailing Address - Street 2:STE 110
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1127
Mailing Address - Country:US
Mailing Address - Phone:360-794-2020
Mailing Address - Fax:360-794-7631
Practice Address - Street 1:14841 179TH AVE SE
Practice Address - Street 2:STE 110
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1127
Practice Address - Country:US
Practice Address - Phone:360-794-2020
Practice Address - Fax:360-794-7631
Is Sole Proprietor?:No
Enumeration Date:2007-01-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1472TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA156303OtherLABOR AND INDUSTRIEDS PIN
WA2001881Medicaid
WA3242COOtherBLUE CROSS PIN
WAGAB29965Medicare PIN
WATO2968Medicare UPIN