Provider Demographics
NPI:1356523807
Name:CONVERSE, JON CHARLES (OD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:CHARLES
Last Name:CONVERSE
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 1:10516 SILVERDALE WAY NW STE 104
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8745
Mailing Address - Country:US
Mailing Address - Phone:360-307-7400
Mailing Address - Fax:
Practice Address - Street 1:10516 SILVERDALE WAY NW STE 104
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8745
Practice Address - Country:US
Practice Address - Phone:360-307-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3170TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2019263Medicaid
WAG8881447Medicare PIN
WAU60618Medicare UPIN
WAG8881448Medicare PIN
WA2019263Medicaid