Provider Demographics
NPI:1245496744
Name:RAMMELL, DORIAN MAX (OD)
Entity type:Individual
Prefix:DR
First Name:DORIAN
Middle Name:MAX
Last Name:RAMMELL
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 1:500 PORT DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1835
Mailing Address - Country:US
Mailing Address - Phone:509-758-8811
Mailing Address - Fax:509-751-1188
Practice Address - Street 1:500 PORT DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-1835
Practice Address - Country:US
Practice Address - Phone:509-758-8811
Practice Address - Fax:509-751-1188
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3114-035152W00000X
WAOD 60108608152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0252321OtherLABOR & INDUSTRY
WA2035350 PINMedicaid
ID808328900 GRPMedicaid
WAP00775620OtherRAILROAD MEDICARE
WAOD 60108608OtherSTATE LICENSE
ID000010174293OtherREGENCE BLUE SHIELD CLARKSTON
ID000010174294OtherREGENCE BLUE SHIELD PULLMAN
00010174293OtherFEDERAL BLUE CROSS
WA0252321OtherCRIME VICTIMS COMPENSATION ACT
ID1245496744OtherBLUE CROSS OF IDAHO
WA2031565 GRPMedicaid
1022RAOtherASURIS
ID808565801 PULLMedicaid
ID808565800 CLKMedicaid
WA1245496744OtherPREMERA BLUE CROSS
WAOD 60108608OtherSTATE LICENSE