Provider Demographics
NPI:1245360072
Name:CREVISTON, STEPHEN H (OD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:H
Last Name:CREVISTON
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 1:601 S PIONEER WAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-4801
Mailing Address - Country:US
Mailing Address - Phone:509-765-2125
Mailing Address - Fax:
Practice Address - Street 1:601 S PIONEER WAY
Practice Address - Street 2:SUITE D
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-4801
Practice Address - Country:US
Practice Address - Phone:509-765-2125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001837152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2012383Medicaid
WAG8850192Medicare PIN
WAU11526Medicare UPIN
WA2012383Medicaid
WAG8850225Medicare PIN
WA5304890001Medicare NSC