Provider Demographics
NPI:1457358657
Name:OHLSEN, NILS W (OD)
Entity Type:Individual
Prefix:
First Name:NILS
Middle Name:W
Last Name:OHLSEN
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 581
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0581
Mailing Address - Country:US
Mailing Address - Phone:509-928-6922
Mailing Address - Fax:
Practice Address - Street 1:15727 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-9544
Practice Address - Country:US
Practice Address - Phone:509-926-0667
Practice Address - Fax:509-922-9849
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002651152W00000X
PAOEG004078152W00000X
IDODP-100587152W00000X
MTOPT-OPT-LIC-4613152W00000X
NH1079152W00000X
WA3589152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023851Medicaid
WA2023851Medicaid
WAU80843Medicare UPIN
WAGAB39018Medicare PIN