Provider Demographics
NPI:1760466015
Name:MACE, SHARI L (OD)
Entity type:Individual
Prefix:
First Name:SHARI
Middle Name:L
Last Name:MACE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:6420 SW MACADAM AVE
Mailing Address - Street 2:SUITE 216
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3507
Mailing Address - Country:US
Mailing Address - Phone:503-244-8601
Mailing Address - Fax:503-244-3013
Practice Address - Street 1:4035 MERCANTILE DR
Practice Address - Street 2:SUITE 216
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2546
Practice Address - Country:US
Practice Address - Phone:503-636-2551
Practice Address - Fax:503-636-3055
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR1928AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR226335Medicaid
OR410043877OtherRAILROAD MEDICARE
ORR151967Medicare PIN
ORT67867Medicare UPIN