Provider Demographics
NPI:1396750717
Name:PAUL STASIK OD PC
Entity type:Organization
Organization Name:PAUL STASIK OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:STASIK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-646-5194
Mailing Address - Street 1:11750 SW BARNES RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5911
Mailing Address - Country:US
Mailing Address - Phone:503-646-5194
Mailing Address - Fax:503-646-9390
Practice Address - Street 1:11750 SW BARNES RD
Practice Address - Street 2:SUITE 120
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5911
Practice Address - Country:US
Practice Address - Phone:503-646-5194
Practice Address - Fax:503-646-9390
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAUL STASIK OD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-31
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2936AT152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty