Provider Demographics
NPI:1528093556
Name:PROVOST, BRET A (OD)
Entity type:Individual
Prefix:DR
First Name:BRET
Middle Name:A
Last Name:PROVOST
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9201 SE 91ST AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97086-3760
Mailing Address - Country:US
Mailing Address - Phone:503-775-2424
Mailing Address - Fax:503-775-6181
Practice Address - Street 1:9201 SE 91ST AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97086-3760
Practice Address - Country:US
Practice Address - Phone:503-775-2424
Practice Address - Fax:503-775-6181
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR3132152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR149916Medicare PIN