Provider Demographics
NPI:1639221690
Name:DEHAAN, RAYMOND KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:KEITH
Last Name:DEHAAN
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 1:310 STILLWELL AVE
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-2119
Mailing Address - Country:US
Mailing Address - Phone:503-842-6363
Mailing Address - Fax:503-842-6204
Practice Address - Street 1:310 STILLWELL AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-2119
Practice Address - Country:US
Practice Address - Phone:503-842-6363
Practice Address - Fax:503-842-6204
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2858T152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182761Medicaid
OR182762Medicaid
OR112117Medicare PIN
ORU56411Medicare UPIN
OR112116Medicare PIN