Provider Demographics
NPI:1730586918
Name:KLAMATH OPHTHALMOLOGY, PC
Entity type:Organization
Organization Name:KLAMATH OPHTHALMOLOGY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:FAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-884-3148
Mailing Address - Street 1:2640 BIEHN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1181
Mailing Address - Country:US
Mailing Address - Phone:541-884-3148
Mailing Address - Fax:541-884-3373
Practice Address - Street 1:628 N 1ST ST
Practice Address - Street 2:SUITE C
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1506
Practice Address - Country:US
Practice Address - Phone:541-947-3357
Practice Address - Fax:541-947-3368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16253207W00000X
ORMD29440207W00000X
OR2599ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty