Provider Demographics
NPI:1811294291
Name:POLSINELLI OPTOMETRY PC
Entity type:Organization
Organization Name:POLSINELLI OPTOMETRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIO
Authorized Official - Middle Name:
Authorized Official - Last Name:POLSINELLI
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:503-342-6853
Mailing Address - Street 1:4859 MEADOWS RD STE 155
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:415-800-7765
Practice Address - Street 1:4859 MEADOWS RD STE 155
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2628
Practice Address - Country:US
Practice Address - Phone:415-800-7763
Practice Address - Fax:415-800-7765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-19
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13359152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAES830AMedicare PIN