Healthcare Provider Details

I. General information

NPI: 1730586918
Provider Name (Legal Business Name): KLAMATH OPHTHALMOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 N 1ST ST SUITE C
LAKEVIEW OR
97630-1506
US

IV. Provider business mailing address

2640 BIEHN ST SUITE 3
KLAMATH FALLS OR
97601-1181
US

V. Phone/Fax

Practice location:
  • Phone: 541-947-3357
  • Fax: 541-947-3368
Mailing address:
  • Phone: 541-884-3148
  • Fax: 541-884-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2599ATI
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD16253
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD29440
License Number StateOR

VIII. Authorized Official

Name: DR. MARK T FAY
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 541-884-3148