Provider Demographics
NPI:1164425948
Name:WOJCIECHOWSKI, SCOTT J (O D)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:J
Last Name:WOJCIECHOWSKI
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6539 SE MILWAUKIE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-5519
Mailing Address - Country:US
Mailing Address - Phone:503-236-6008
Mailing Address - Fax:503-236-2057
Practice Address - Street 1:6539 SE MILWAUKIE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5519
Practice Address - Country:US
Practice Address - Phone:503-236-6008
Practice Address - Fax:503-236-2057
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2015-01-27
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
OROR1735AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000PHLBBOtherPTAN
OR0906010001Medicare NSC