Provider Demographics
NPI:1306493978
Name:MCILHATTAN, OWEN SILAS (OD)
Entity type:Individual
Prefix:
First Name:OWEN
Middle Name:SILAS
Last Name:MCILHATTAN
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 1:24719 SE RUGG RD
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-7353
Mailing Address - Country:US
Mailing Address - Phone:503-334-7560
Mailing Address - Fax:
Practice Address - Street 1:4704 SE HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3250
Practice Address - Country:US
Practice Address - Phone:503-235-6639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60966063152W00000X
OR4465152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist