=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609920701
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNE ELIZABETH BERK O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 08/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13180 SE 169TH AVE STE 104
-----------------------------------------------------
City | HAPPY VALLEY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97086-8727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-698-2375
-----------------------------------------------------
Fax | 503-698-3398
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13180 SE 169TH AVE STE 104
-----------------------------------------------------
City | HAPPY VALLEY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97086-8727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-698-2375
-----------------------------------------------------
Fax | 503-698-3398
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1749ATI
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
=====================================================
Legacy Identifiers
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 1749ATI
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State | OR
-----------------------------------------------------
Identifier Issuer | OD LICENSE NUMBER
-----------------------------------------------------
Identifier #2
-----------------------------------------------------
Identifier Code | 120345
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | OR
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
Identifier #3
-----------------------------------------------------
Identifier Code | 1508037607
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State |
-----------------------------------------------------
Identifier Issuer | ORGANIZATIONAL (GROUP) NPI
-----------------------------------------------------
Identifier #4
-----------------------------------------------------
Identifier Code | R0000WDBCW
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State |
-----------------------------------------------------
Identifier Issuer | MEDICARE GROUP PIN
-----------------------------------------------------
=====================================================
Proprietary Identifiers Ever Reported
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 120345
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | OR
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
Identifier #2
-----------------------------------------------------
Identifier Code | 1508037607
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State |
-----------------------------------------------------
Identifier Issuer | ORGANIZATIONAL (GROUP) NPI
-----------------------------------------------------
Identifier #3
-----------------------------------------------------
Identifier Code | 1749ATI
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State | OR
-----------------------------------------------------
Identifier Issuer | OD LICENSE NUMBER
-----------------------------------------------------
Identifier #4
-----------------------------------------------------
Identifier Code | R0000WDBCW
-----------------------------------------------------
Identifier Type | OTHER
-----------------------------------------------------
Identifier State |
-----------------------------------------------------
Identifier Issuer | MEDICARE GROUP PIN
-----------------------------------------------------