Provider Demographics
NPI:1902088776
Name:ST LUKES EYE CLINIC PC
Entity Type:Organization
Organization Name:ST LUKES EYE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-698-2300
Mailing Address - Street 1:10365 SE SUNNYSIDE RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5741
Mailing Address - Country:US
Mailing Address - Phone:503-698-2300
Mailing Address - Fax:503-698-2308
Practice Address - Street 1:10365 SE SUNNYSIDE RD
Practice Address - Street 2:SUITE 150
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5741
Practice Address - Country:US
Practice Address - Phone:503-698-2300
Practice Address - Fax:503-698-2308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR35519207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067231Medicaid
OR20W00000XOtherTAXONOMY
ORE20649Medicare UPIN
OR1265518666Medicare PIN