Provider Demographics
NPI:1629193602
Name:PORTLAND OPTICAL
Entity Type:Organization
Organization Name:PORTLAND OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:TIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-942-1010
Mailing Address - Street 1:5600 N PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2023
Mailing Address - Country:US
Mailing Address - Phone:405-942-1010
Mailing Address - Fax:405-942-0115
Practice Address - Street 1:5600 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2023
Practice Address - Country:US
Practice Address - Phone:405-942-1010
Practice Address - Fax:405-942-0115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKF332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier