Healthcare Provider Details

I. General information

NPI: 1164425948
Provider Name (Legal Business Name): SCOTT J WOJCIECHOWSKI O D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

6539 SE MILWAUKIE AVE
PORTLAND OR
97202-5519
US

IV. Provider business mailing address

6539 SE MILWAUKIE AVE
PORTLAND OR
97202-5519
US

V. Phone/Fax

Practice location:
  • Phone: 503-236-6008
  • Fax: 503-236-2057
Mailing address:
  • Phone: 503-236-6008
  • Fax: 503-236-2057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOR1735AT
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: