Basic Information
| Provider Information | |||||||||
| NPI: | 1487721023 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OREGON EYE SPECIALISTS PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE SIGHT SHOP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 6420 S MACADAM AVE STE 160 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032448601 | ||||||||
| FaxNumber: | 5032443013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 07/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GATTEY | ||||||||
| AuthorizedOfficialFirstName: | DEVIN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | OPHTHALMOLOGIST, COMPANY PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5032448601 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 07894-4 | 05 | OR | MEDICAID | 14958-3 | 05 | OR | MEDICAID | 22634-4 | 05 | OR | MEDICAID | CS5592 | 01 | RR MEDICARE PTAN | OTHER | 02262-6 | 05 | OR | MEDICAID | 06527-1 | 05 | OR | MEDICAID | 22633-5 | 05 | OR | MEDICAID | 26075-2 | 05 | OR | MEDICAID | 02557-2 | 05 | OR | MEDICAID | 04877-7 | 05 | OR | MEDICAID | 23334-9 | 05 | OR | MEDICAID | CH568 | 01 | RR MEDICARE PTAN | OTHER | 27152-8 | 05 | OR | MEDICAID | 27665-8 | 05 | OR | MEDICAID | 28849-0 | 05 | OR | MEDICAID | DA3276 | 01 | RR MEDICARE PTAN | OTHER | 21536-8 | 05 | OR | MEDICAID | 22935-3 | 05 | OR | MEDICAID | 06008-7 | 05 | OR | MEDICAID |