Provider Demographics
NPI:1669400149
Name:STINE, JONATHAN E (OD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:E
Last Name:STINE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:8700 NE VANCOUVER MALL DR
Mailing Address - Street 2:SUITE 168
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6750
Mailing Address - Country:US
Mailing Address - Phone:360-254-5990
Mailing Address - Fax:360-944-6090
Practice Address - Street 1:8700 NE VANCOUVER MALL DR
Practice Address - Street 2:SUITE 168
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6750
Practice Address - Country:US
Practice Address - Phone:360-254-5990
Practice Address - Fax:360-944-6090
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1741TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU24072Medicare UPIN
WAG000615439Medicare PIN