Provider Demographics
NPI:1699887158
Name:PAULSON, WAYNE ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ROBERT
Last Name:PAULSON
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 1:586 5TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-9720
Mailing Address - Country:US
Mailing Address - Phone:541-469-7775
Mailing Address - Fax:
Practice Address - Street 1:586 5TH ST STE 300
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9720
Practice Address - Country:US
Practice Address - Phone:541-469-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1359ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR131124Medicare ID - Type Unspecified
OR131122Medicare ID - Type UnspecifiedGROUP
ORT67994Medicare UPIN