Provider Demographics
NPI:1780972778
Name:TIGARD VISION WORLD, P.C.
Entity type:Organization
Organization Name:TIGARD VISION WORLD, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-703-7451
Mailing Address - Street 1:9975 SW FREWING ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5091
Mailing Address - Country:US
Mailing Address - Phone:503-906-3596
Mailing Address - Fax:503-906-1014
Practice Address - Street 1:9975 SW FREWING ST
Practice Address - Street 2:SUITE 130
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5091
Practice Address - Country:US
Practice Address - Phone:503-906-3596
Practice Address - Fax:503-906-1014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-12
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X
OR1863T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500774223Medicaid