Basic Information
| Provider Information | |||||||||
| NPI: | 1669706313 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYE HEALTH NORTHWEST P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11086 SE OAK ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972226692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035572020 | ||||||||
| FaxNumber: | 5033445110 | ||||||||
| Practice Location | |||||||||
| Address1: | 1955 NW NORTHRUP ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972091614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032272020 | ||||||||
| FaxNumber: | 5032220614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2009 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5033445101 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EYE HEALTH NORTHWEST P.C. | ||||||||
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| NPICertificationDate: | 12/21/2021 | ||||||||
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 |