Provider Demographics
NPI:1932271921
Name:HALL, ROGER WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:WILLIAM
Last Name:HALL
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 1:10217 19TH AVE SE STE 102
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-4266
Mailing Address - Country:US
Mailing Address - Phone:425-316-9400
Mailing Address - Fax:425-316-8820
Practice Address - Street 1:10217 19TH AVE SE STE 102
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-4266
Practice Address - Country:US
Practice Address - Phone:425-316-9400
Practice Address - Fax:425-316-8820
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1751TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2024818Medicaid
WA4104110001Medicare NSC
WAT01995Medicare UPIN
WA2024818Medicaid