Provider Demographics
NPI:1841222064
Name:STASIK, PAUL M (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:M
Last Name:STASIK
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 1:13160 SW WHITMORE RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-9073
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11750 SW BARNES RD
Practice Address - Street 2:SUITE 120
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5911
Practice Address - Country:US
Practice Address - Phone:503-646-5194
Practice Address - Fax:503-646-9390
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2936ATI152W00000X
OR2936AT152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V10511Medicare UPIN