Healthcare Provider Details

I. General information

NPI: 1184305013
Provider Name (Legal Business Name): ETIENNE BINGHAM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 14TH AVE SE
ALBANY OR
97322-6956
US

IV. Provider business mailing address

1595 WAVERLY DR SE APT 201
ALBANY OR
97322-8138
US

V. Phone/Fax

Practice location:
  • Phone: 541-928-1667
  • Fax:
Mailing address:
  • Phone: 857-361-9339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberAT4700
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: