Provider Demographics
NPI:1487838157
Name:DAVID A DROTZMANN OD PC
Entity Type:Organization
Organization Name:DAVID A DROTZMANN OD PC
Other - Org Name:LIFETIME VISION SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:DROTZMANN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:541-567-6623
Mailing Address - Street 1:1060 W ELM STREET, SUITE 135
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-2724
Mailing Address - Country:US
Mailing Address - Phone:541-567-6623
Mailing Address - Fax:541-564-0277
Practice Address - Street 1:1060 W ELM STREET, SUITE 135
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2724
Practice Address - Country:US
Practice Address - Phone:541-567-6623
Practice Address - Fax:541-564-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2709ATI152W00000X
WAOD00003278152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR295499Medicaid
OR295499Medicaid
OR5089390001Medicare NSC
ORU62110Medicare UPIN