Healthcare Provider Details

I. General information

NPI: 1730366246
Provider Name (Legal Business Name): ST LUKES EYE CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10365 SE SUNNYSIDE RD SUITE 150
CLACKAMAS OR
97015-5741
US

IV. Provider business mailing address

10365 SE SUNNYSIDE RD SUITE 150
CLACKAMAS OR
97015-5741
US

V. Phone/Fax

Practice location:
  • Phone: 503-698-2300
  • Fax: 503-698-2308
Mailing address:
  • Phone: 503-698-2300
  • Fax: 503-698-2308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberDO07540
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier067231
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: DR. JAY GORDON BETTS
Title or Position: OPHTHALMOLOGIST
Credential: D.O.
Phone: 503-698-2300