Provider Demographics
NPI:1245515394
Name:SUKHOVOLSKIY, GLEB V (OD)
Entity type:Individual
Prefix:DR
First Name:GLEB
Middle Name:V
Last Name:SUKHOVOLSKIY
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:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:2915 S ALDER ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-4803
Practice Address - Country:US
Practice Address - Phone:253-473-0275
Practice Address - Fax:253-473-0706
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60483702OPT-OP152W00000X
MTOPT-OPT-LIC-3679152W00000X
WAOD60483702152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2121025Medicaid