MEDICARE: YUESUM TO OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3153T	OR
2	152W00000X	Optometrist	10865T	CA

General Provider Information

NPI Number	:	1144324732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YUESUM TO OD

Provider Business Mailing Address
First Line	:	2368 W BURNSIDE ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97210-3538
Country	:	US
Telephone Number	:	503-830-0265
Fax Number	:	503-335-7973

Provider Business Practice Location Address
First Line	:	3333 SE BELMONT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-4244
Country	:	US
Telephone Number	:	503-335-7173
Fax Number	:	503-335-7973

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	07/08/2007

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Directions to “ YUESUM TO OD” Practice Location

Language	Start Address	Practice Location

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