Provider Demographics
NPI:1871509653
Name:ATIKUNE, EZRA (OD)
Entity Type:Individual
Prefix:DR
First Name:EZRA
Middle Name:
Last Name:ATIKUNE
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 1:3838 N MISSISSIPPI AVE
Mailing Address - Street 2:OPTIK PDX
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1161
Mailing Address - Country:US
Mailing Address - Phone:503-206-3937
Mailing Address - Fax:503-206-3690
Practice Address - Street 1:3838 N MISSISSIPPI AVE
Practice Address - Street 2:OPTIK PDX
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1161
Practice Address - Country:US
Practice Address - Phone:503-206-3937
Practice Address - Fax:503-206-3690
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2011-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009105152W00000X
OR3344AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210743Medicare ID - Type UnspecifiedMEDICARE
ILV03358Medicare UPIN