Provider Demographics
NPI:1518014737
Name:EBERHARDT, NEIL SCOTT (OD)
Entity type:Individual
Prefix:DR
First Name:NEIL
Middle Name:SCOTT
Last Name:EBERHARDT
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 1:1427 N LAVENTURE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2765
Mailing Address - Country:US
Mailing Address - Phone:360-424-0553
Mailing Address - Fax:
Practice Address - Street 1:1427 N LAVENTURE RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-2765
Practice Address - Country:US
Practice Address - Phone:360-424-0553
Practice Address - Fax:360-424-9603
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1991152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2013597Medicaid
WA2013597Medicaid
WAGAB39667Medicare ID - Type Unspecified