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General NPI Number Information
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NPI Number | 1235281379
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Entity Type | Individual
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Provider Name | DEREK JEN KON LOUIE BS, MS, OD
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Gender | Male
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Dates
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Enumeration Date | 01/17/2007
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Last Update Date | 02/24/2022
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Provider Practice Location Address
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Address Line | 3375 SW TERWILLIGER BLVD
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City | PORTLAND
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State | OR
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Zip | 97239
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Country | US
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Telephone | 503-494-3000
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Fax | 503-494-3909
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Provider Business Mailing Address
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Address Line | 3303 S BOND AVE
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City | PORTLAND
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State | OR
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Zip | 97239-4501
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Country | US
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Telephone | 503-494-3000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3196ATI
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License Number State | OR
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