Provider Demographics
NPI:1770972515
Name:NORTHWEST OPTOMETRIC ASSOCIATES INC
Entity type:Organization
Organization Name:NORTHWEST OPTOMETRIC ASSOCIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARI
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-473-8039
Mailing Address - Street 1:1522 SW SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2626
Mailing Address - Country:US
Mailing Address - Phone:503-473-8039
Mailing Address - Fax:503-473-8952
Practice Address - Street 1:1522 SW SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2626
Practice Address - Country:US
Practice Address - Phone:503-473-8039
Practice Address - Fax:503-473-8952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2151ATI152W00000X
OR3023ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1164622288OtherNPI OF SHERWOOD LOCATION UNDER SAME TAX ID
OR105088Medicare UPIN