Provider Demographics
NPI:1134204159
Name:KREBSBACH, JOHN BERNARD (O D)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BERNARD
Last Name:KREBSBACH
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 WATERCREST RD
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1034
Mailing Address - Country:US
Mailing Address - Phone:503-357-5390
Mailing Address - Fax:
Practice Address - Street 1:518 SE OAK ST STE 2020
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4896
Practice Address - Country:US
Practice Address - Phone:503-648-2020
Practice Address - Fax:503-648-0868
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1571ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130026Medicaid
OR130026Medicaid