Provider Demographics
NPI:1649560426
Name:OPTIK PDX LLC
Entity Type:Organization
Organization Name:OPTIK PDX LLC
Other - Org Name:OPTIK PDX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EZRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ATIKUNE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-206-3937
Mailing Address - Street 1:3838 N MISSISSIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1161
Mailing Address - Country:US
Mailing Address - Phone:503-206-3937
Mailing Address - Fax:503-206-3690
Practice Address - Street 1:3838 N MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1161
Practice Address - Country:US
Practice Address - Phone:503-206-3937
Practice Address - Fax:503-206-3690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3344AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty