Provider Demographics
NPI:1851585038
Name:GATEWAY EYE CLINIC, P.C.
Entity Type:Organization
Organization Name:GATEWAY EYE CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHESTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-252-2467
Mailing Address - Street 1:10502 NE WASCO ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3948
Mailing Address - Country:US
Mailing Address - Phone:503-252-2467
Mailing Address - Fax:503-252-0670
Practice Address - Street 1:10502 NE WASCO ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3948
Practice Address - Country:US
Practice Address - Phone:503-252-2467
Practice Address - Fax:503-252-0670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR013545Medicaid
ORE28574Medicare UPIN
OR013545Medicaid