Provider Demographics
NPI:1326030883
Name:AGOST, BRETT (OD)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:AGOST
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 1:125 NW MILLER
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030
Mailing Address - Country:US
Mailing Address - Phone:503-665-3813
Mailing Address - Fax:503-492-2313
Practice Address - Street 1:125 NW MILLER
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:503-665-3813
Practice Address - Fax:503-492-2313
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2497T152W00000X
OR2497ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR120167Medicaid
ORU44761Medicare UPIN
OR120167Medicaid