=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558811778
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MACADAM EYE CARE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2016
-----------------------------------------------------
Last Update Date | 10/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5901 SW MACADAM AVE STE 105
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97239-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-222-2990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5901 SW MACADAM AVE STE 105
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97239-3620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-222-2990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT / OWNER
-----------------------------------------------------
Name | DR. MERSEDEH SAFARI SNIDER
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 971-645-8173
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3134AT
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------