Provider Demographics
NPI:1255432241
Name:BURY, CHESTER I (OD)
Entity type:Individual
Prefix:DR
First Name:CHESTER
Middle Name:I
Last Name:BURY
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 1:7250 PACIFIC AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-7128
Mailing Address - Country:US
Mailing Address - Phone:253-472-1168
Mailing Address - Fax:253-475-2652
Practice Address - Street 1:7250 PACIFIC AVE STE 1
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7128
Practice Address - Country:US
Practice Address - Phone:253-472-1168
Practice Address - Fax:253-475-2652
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3003152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2015048Medicaid
WA2015048Medicaid
WAGAB00918Medicare PIN