Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1104937762 |
---|---|
Provider Name | Mr. Thomas George White |
First Address | Portland, OR 97219-3228 |
Second Address | Beaverton, OR 97005-3460 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 08/07/2007 |