Individual
CHAD RYAN BOUTERSE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
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
Update your record
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