Provider Demographics
NPI:1982758868
Name:CORNELL EYECARE GROUP, INC
Entity Type:Organization
Organization Name:CORNELL EYECARE GROUP, INC
Other - Org Name:CORNELL EYECARE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-643-5556
Mailing Address - Street 1:12955 NW CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5863
Mailing Address - Country:US
Mailing Address - Phone:503-643-5556
Mailing Address - Fax:503-641-2515
Practice Address - Street 1:12955 NW CORNELL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5863
Practice Address - Country:US
Practice Address - Phone:503-643-5556
Practice Address - Fax:503-641-2515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2784ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR18428-3Medicaid
ORR130311Medicare PIN
OR18428-3Medicaid