Provider Demographics
NPI:1700833209
Name:KIRK PARKER, OD PC
Entity Type:Organization
Organization Name:KIRK PARKER, OD PC
Other - Org Name:CEDAR HILLS VISION SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:J
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-292-5221
Mailing Address - Street 1:1517 SW MARLOW AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5101
Mailing Address - Country:US
Mailing Address - Phone:503-292-5221
Mailing Address - Fax:503-297-3937
Practice Address - Street 1:1517 SW MARLOW AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5101
Practice Address - Country:US
Practice Address - Phone:503-292-5221
Practice Address - Fax:503-297-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5991080001Medicare NSC
R135515Medicare PIN