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General NPI Number Information
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NPI Number | 1649560426
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Entity Type | Organization
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Legal Business Name | OPTIK PDX LLC
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Dates
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Enumeration Date | 04/13/2011
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Last Update Date | 04/13/2011
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Provider Practice Location Address
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Address Line | 3838 N MISSISSIPPI AVE
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City | PORTLAND
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State | OR
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Zip | 97227-1161
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Country | US
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Telephone | 503-206-3937
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Fax | 503-206-3690
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Provider Business Mailing Address
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Address Line | 3838 N MISSISSIPPI AVE
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City | PORTLAND
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State | OR
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Zip | 97227-1161
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Country | US
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Telephone | 503-206-3937
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Fax | 503-206-3690
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Authorized Official
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Title or Position | MEMBER/OPTOMETRIST
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Name | DR. EZRA ATIKUNE
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Credential | O.D.
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Telephone | 503-206-3937
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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 | 3344AT
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License Number State | OR
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