Provider Demographics
NPI:1942307533
Name:SALIBELLO, COSMO (OD)
Entity Type:Individual
Prefix:DR
First Name:COSMO
Middle Name:
Last Name:SALIBELLO
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 1:9898 SW LYNWOOD TER
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-4341
Mailing Address - Country:US
Mailing Address - Phone:503-296-7655
Mailing Address - Fax:503-296-7655
Practice Address - Street 1:23500 NE SANDY BLVD
Practice Address - Street 2:LOCATED INSIDE WALMART
Practice Address - City:WOOD VILLAGE
Practice Address - State:OR
Practice Address - Zip Code:97060-9653
Practice Address - Country:US
Practice Address - Phone:503-667-8869
Practice Address - Fax:503-667-7598
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1658 ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR212994OtherHEALTH NET ID NUMBER
OR214056Medicaid
ORT68091Medicare UPIN
OOOODHDPSMedicare ID - Type UnspecifiedCMS ID NUMBER