Provider Demographics
NPI:1215135066
Name:BRIDGEPORT EYE PHYSICIANS, LLC
Entity type:Organization
Organization Name:BRIDGEPORT EYE PHYSICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:W
Authorized Official - Last Name:MADSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-971-1514
Mailing Address - Street 1:20015 SW PACIFIC HWY STE 150
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9316
Mailing Address - Country:US
Mailing Address - Phone:503-610-1025
Mailing Address - Fax:503-610-1596
Practice Address - Street 1:20015 SW PACIFIC HWY STE 150
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9316
Practice Address - Country:US
Practice Address - Phone:503-610-1025
Practice Address - Fax:503-610-1596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2023-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1670ATI152W00000X
152W00000X, 207W00000X
ORMD25517207W00000X
ORDO22937207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty