Provider Demographics
NPI:1245340116
Name:MCDOUGALL, KENTON SCOTT (OD)
Entity type:Individual
Prefix:
First Name:KENTON
Middle Name:SCOTT
Last Name:MCDOUGALL
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 1:298 S MAIN ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2447
Mailing Address - Country:US
Mailing Address - Phone:509-684-2221
Mailing Address - Fax:509-684-6222
Practice Address - Street 1:298 S MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2447
Practice Address - Country:US
Practice Address - Phone:509-684-2221
Practice Address - Fax:509-684-6222
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001246152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0022969OtherLABOR AND INDUSTRIES
WA2030500Medicaid
WA0022969OtherLABOR AND INDUSTRIES
WAT02357Medicare UPIN