Basic Information
| Provider Information | |||||||||
| NPI: | 1578584702 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GLAUCOMA ASSOCIATES & CONSULTATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 NW 22ND AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034138202 | ||||||||
| FaxNumber: | 5034136937 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 NW 22ND AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034138202 | ||||||||
| FaxNumber: | 5034136937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 03/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | MANSBERGER | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTHALMOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 5034136453 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD MPH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD22167 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 213408 | 05 | OR | MEDICAID |