Provider Demographics
NPI:1306050919
Name:GURTISEN, JAMES MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MICHAEL
Last Name:GURTISEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 E HISTORIC COLUMBIA RIVER HWY
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-2069
Mailing Address - Country:US
Mailing Address - Phone:503-492-3897
Mailing Address - Fax:503-665-4137
Practice Address - Street 1:226 E HISTORIC COLUMBIA RIVER HWY
Practice Address - Street 2:
Practice Address - City:TROUTDALE
Practice Address - State:OR
Practice Address - Zip Code:97060-2069
Practice Address - Country:US
Practice Address - Phone:503-492-3897
Practice Address - Fax:503-665-4137
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2320ATI152W00000X
WAOD00001998152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR031497Medicaid
WA2019628Medicaid
OR00WFBSVAMedicare ID - Type Unspecified
OR031497Medicaid
WA2019628Medicaid
ORU19271Medicare UPIN