Healthcare Provider Details

I. General information

NPI: 1750614426
Provider Name (Legal Business Name): MICHAEL R OWEN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 E 1ST ST
NEWBERG OR
97132-2912
US

IV. Provider business mailing address

620 E 1ST ST
NEWBERG OR
97132-2912
US

V. Phone/Fax

Practice location:
  • Phone: 503-847-9183
  • Fax: 971-832-8578
Mailing address:
  • Phone: 503-847-9183
  • Fax: 971-832-8578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3316ATI
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: