Provider Demographics
NPI:1346323367
Name:GRESHAM VISION SOURCE PC
Entity Type:Organization
Organization Name:GRESHAM VISION SOURCE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TUAN
Authorized Official - Middle Name:TU
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-669-1992
Mailing Address - Street 1:929 NE 181ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-6757
Mailing Address - Country:US
Mailing Address - Phone:503-669-1992
Mailing Address - Fax:503-618-8262
Practice Address - Street 1:929 NE 181ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-6757
Practice Address - Country:US
Practice Address - Phone:503-669-1992
Practice Address - Fax:503-618-8262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2987AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORV07577Medicaid
OR117114OtherGROUP PIN
OR117114OtherGROUP PIN
ORV07577Medicare UPIN