Provider Demographics
NPI:1437247533
Name:WOJCIECHOWSKI, BRUCE ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ROBERT
Last Name:WOJCIECHOWSKI
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 1:15259 SE 82ND DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6609
Mailing Address - Country:US
Mailing Address - Phone:503-657-0321
Mailing Address - Fax:503-657-7066
Practice Address - Street 1:15259 SE 82ND DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6609
Practice Address - Country:US
Practice Address - Phone:503-657-0321
Practice Address - Fax:503-657-7066
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1620ATI152W00000X
WAOD00001458152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR282442Medicaid
R0000WFBNFMedicare ID - Type Unspecified
T68280Medicare UPIN