Provider Demographics
NPI:1073694980
Name:POLSINELLI, ELIO JR (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIO
Middle Name:
Last Name:POLSINELLI
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4859 MEADOWS RD STE 155
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4859 MEADOWS RD STE 155
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2628
Practice Address - Country:US
Practice Address - Phone:415-800-7763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT4542152W00000X
CAOPT 13359T152W00000X
NJ27OA00605800152W00000X
NYTUV 007065152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV00225Medicare UPIN
CAES844ZMedicare PIN