Individual
CHAD RYAN BOUTERSE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
500 PORT DR, CLARKSTON, WA 99403-1835
(509) 758-8811
(509) 751-1188
Mailing address
500 PORT DR, CLARKSTON, WA 99403-1835
(509) 758-8811
(509) 751-1188
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
5101016467
MI
207W00000X
Ophthalmology Physician
O 570
ID
207W00000X
Ophthalmology Physician
Primary
OP60127012
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0080BO
ASURIS - CLARKSTON
—
01
—
0081BO
ASURIS - PULLMAN
—
01
—
1699896167
FEDERAL BLUE CROSS
—
01
—
258958
WASHINGTON LABOR & INDUSTRY
WA
01
—
808567100
MEDICAID - CLARKSTON
ID
01
—
808567101
MEDICAID - PULLMAN
ID
05
—
8564387
—
WA
01
—
O 0570
STATE LICENSE
ID
01
—
OP60127012
STATE LICENSE
WA
Enumeration date
04/03/2007
Last updated
05/28/2010
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