Healthcare Provider Details

I. General information

NPI: 1326200809
Provider Name (Legal Business Name): JOHN WILLIAM RESKI O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15259 SE 82ND DR SUITE 101
CLACKAMAS OR
97015-6609
US

IV. Provider business mailing address

15259 SE 82ND DR SUITE 101
CLACKAMAS OR
97015-6609
US

V. Phone/Fax

Practice location:
  • Phone: 503-657-0321
  • Fax: 503-657-7066
Mailing address:
  • Phone: 503-657-0321
  • Fax: 503-657-7066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number3269ATI
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOD60026416
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: