Provider Demographics
NPI:1285366575
Name:ITKIN, BRIANNA TAYLOR (OD)
Entity type:Individual
Prefix:DR
First Name:BRIANNA
Middle Name:TAYLOR
Last Name:ITKIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20695 NW HIGHLAND CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-3102
Mailing Address - Country:US
Mailing Address - Phone:703-577-8646
Mailing Address - Fax:
Practice Address - Street 1:7485 SW BRIDGEPORT RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7207
Practice Address - Country:US
Practice Address - Phone:971-202-1932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4640152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist