Provider Demographics
NPI:1356345078
Name:MARCUSON, JEREMY KYLE (OD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:KYLE
Last Name:MARCUSON
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 1:26 W H ST STE A
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-7167
Mailing Address - Country:US
Mailing Address - Phone:509-276-6932
Mailing Address - Fax:509-276-1608
Practice Address - Street 1:26 W. H ST.
Practice Address - Street 2:STUITE A
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006
Practice Address - Country:US
Practice Address - Phone:509-276-6932
Practice Address - Fax:509-276-1608
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3884152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2030880Medicaid
WA8856269Medicare PIN
WAV06711Medicare UPIN
WA5022510001Medicare NSC