Provider Demographics
NPI:1073670170
Name:CARMIENCKE, CHRISTOPHER (OD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:CARMIENCKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:KIT
Other - Middle Name:
Other - Last Name:CARMIENCKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:452 NE GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-1134
Mailing Address - Country:US
Mailing Address - Phone:541-382-5701
Mailing Address - Fax:541-382-5702
Practice Address - Street 1:452 NE GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4645
Practice Address - Country:US
Practice Address - Phone:541-382-5701
Practice Address - Fax:541-382-5702
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1221 ATI152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR03256-5Medicaid
ORT 67492Medicare UPIN
OR03256-5Medicaid
OR109031Medicare ID - Type Unspecified