Provider Demographics
NPI:1407821499
Name:FRIES, JEFFREY A (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:FRIES
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 1:500 NE MULTNOMAH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2031
Mailing Address - Country:US
Mailing Address - Phone:503-813-4756
Mailing Address - Fax:877-821-5101
Practice Address - Street 1:1230 7TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3166
Practice Address - Country:US
Practice Address - Phone:877-213-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3445152W00000X
WAOD00003445152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2021814Medicaid
AB15452Medicare ID - Type Unspecified
WA2021814Medicaid
U70160Medicare UPIN