Provider Demographics
NPI:1235271511
Name:AN, JOSEPH JUNGHO (OD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:JUNGHO
Last Name:AN
Suffix:
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 1:1380 E POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8004
Mailing Address - Country:US
Mailing Address - Phone:503-760-2525
Mailing Address - Fax:503-895-2020
Practice Address - Street 1:1380 E POWELL BLVD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8004
Practice Address - Country:US
Practice Address - Phone:503-760-2525
Practice Address - Fax:503-895-2020
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR2825ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU86859Medicare UPIN