Healthcare Provider Details

I. General information

NPI: 1063403798
Provider Name (Legal Business Name): BETH TOSHIKO KINOSHITA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2043 COLLEGE WAY
FOREST GROVE OR
97116-1756
US

IV. Provider business mailing address

2043 COLLEGE WAY
FOREST GROVE OR
97116-1756
US

V. Phone/Fax

Practice location:
  • Phone: 503-352-3140
  • Fax: 503-352-2929
Mailing address:
  • Phone: 503-352-1111
  • Fax: 503-352-2929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number3146T
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: