Provider Demographics
NPI:1366430936
Name:PALM, TOBY (OD)
Entity type:Individual
Prefix:DR
First Name:TOBY
Middle Name:
Last Name:PALM
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 1:201 DAKOTA STREET
Mailing Address - Street 2:
Mailing Address - City:SUTHERLIN
Mailing Address - State:OR
Mailing Address - Zip Code:97479-9113
Mailing Address - Country:US
Mailing Address - Phone:541-459-4333
Mailing Address - Fax:541-459-7512
Practice Address - Street 1:201 DAKOTA STREET
Practice Address - Street 2:
Practice Address - City:SUTHERLIN
Practice Address - State:OR
Practice Address - Zip Code:97479-9113
Practice Address - Country:US
Practice Address - Phone:541-459-4333
Practice Address - Fax:541-459-7512
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1327152W00000X
OR2872T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR137404Medicare PIN