Basic Information
Provider Information | |||||||||
NPI: | 1124353362 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EYE HEALTH NORTHWEST P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 22009 | ||||||||
Address2: |   | ||||||||
City: | MILWAUKIE | ||||||||
State: | OR | ||||||||
PostalCode: | 972692009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5035587372 | ||||||||
FaxNumber: | 5033445110 | ||||||||
Practice Location | |||||||||
Address1: | 11086 SE OAK ST | ||||||||
Address2: |   | ||||||||
City: | MILWAUKIE | ||||||||
State: | OR | ||||||||
PostalCode: | 972226692 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036564221 | ||||||||
FaxNumber: | 5036564249 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2009 | ||||||||
LastUpdateDate: | 02/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KIM | ||||||||
AuthorizedOfficialFirstName: | SHANE | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5032552291 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | EYE HEALTH NORTHWEST P.C. | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 02/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 085006 | 05 | OR |   | MEDICAID |