Provider Demographics
NPI:1760524268
Name:MIYAMOTO, SANDRA J (OD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:J
Last Name:MIYAMOTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4859 MEADOWS RD
Mailing Address - Street 2:STE 155
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2628
Mailing Address - Country:US
Mailing Address - Phone:503-342-6853
Mailing Address - Fax:
Practice Address - Street 1:4859 MEADOWS RD STE 155
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2628
Practice Address - Country:US
Practice Address - Phone:503-342-6853
Practice Address - Fax:503-342-6185
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007047152W00000X
CA13422152W00000X
ORAT4601152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometrist