Basic Information
| Provider Information | |||||||||
| NPI: | 1760466015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACE | ||||||||
| FirstName: | SHARI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6420 SW MACADAM AVE | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032448601 | ||||||||
| FaxNumber: | 5032443013 | ||||||||
| Practice Location | |||||||||
| Address1: | 4035 MERCANTILE DR | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970352546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036362551 | ||||||||
| FaxNumber: | 5036363055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 05/29/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1928AT | OR | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 226335 | 05 | OR | MEDICAID | 410043877 | 01 | OR | RAILROAD MEDICARE | OTHER |