Provider Demographics
NPI:1104813781
Name:RETINA NORTHWEST P.C.
Entity type:Organization
Organization Name:RETINA NORTHWEST P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:COE
Authorized Official - Phone:503-274-2121
Mailing Address - Street 1:4225 NE ST JAMES RD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-2148
Mailing Address - Country:US
Mailing Address - Phone:503-274-2121
Mailing Address - Fax:866-843-7990
Practice Address - Street 1:5440 SW WESTGATE DR STE 217
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2421
Practice Address - Country:US
Practice Address - Phone:503-274-2121
Practice Address - Fax:866-843-7990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR02670693207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR104713Medicare PIN
ORR104718Medicare PIN