Basic Information
| Provider Information | |||||||||
| NPI: | 1346242997 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUMLEY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | HUGH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6420 S MACADAM AVE STE 160 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032448601 | ||||||||
| FaxNumber: | 5032443013 | ||||||||
| Practice Location | |||||||||
| Address1: | 18345 SW ALEXANDER ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ALOHA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970063960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036422505 | ||||||||
| FaxNumber: | 5036499556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1337T | OR | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 226344 | 05 | OR | MEDICAID |