Provider Demographics
NPI:1376680454
Name:OSWEGO OPTIQUE INC
Entity Type:Organization
Organization Name:OSWEGO OPTIQUE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-636-6900
Mailing Address - Street 1:466 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3127
Mailing Address - Country:US
Mailing Address - Phone:503-636-6900
Mailing Address - Fax:503-636-2985
Practice Address - Street 1:466 2ND ST
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3127
Practice Address - Country:US
Practice Address - Phone:503-636-6900
Practice Address - Fax:503-636-2985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1934T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR136201Medicare PIN