Provider Demographics
NPI:1689669624
Name:HARWIN, FREDRIC M (MSC, BCO, BADO, FAMI)
Entity Type:Individual
Prefix:MR
First Name:FREDRIC
Middle Name:M
Last Name:HARWIN
Suffix:
Gender:M
Credentials:MSC, BCO, BADO, FAMI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 NW LOVEJOY ST
Mailing Address - Street 2:STE 306
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2859
Mailing Address - Country:US
Mailing Address - Phone:503-229-8490
Mailing Address - Fax:503-224-0740
Practice Address - Street 1:2525 NW LOVEJOY ST
Practice Address - Street 2:STE 306
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2859
Practice Address - Country:US
Practice Address - Phone:503-229-8490
Practice Address - Fax:503-224-0740
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2011-08-24
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
OR516802891744P3200X
OR516802-89156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500605356Medicaid
OR01621900001OtherREGENCE BCBS DME SUPPLIER
OR500605356Medicaid