Healthcare Provider Details

I. General information

NPI: 1427802156
Provider Name (Legal Business Name): JOEBELLE PASTORES BONETE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22640 SE STARK ST
GRESHAM OR
97030-2684
US

IV. Provider business mailing address

22640 SE STARK ST
GRESHAM OR
97030-2684
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-0441
  • Fax:
Mailing address:
  • Phone: 503-667-0441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4725
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: