Provider Demographics
NPI:1366591026
Name:BOURDAGE, RODNEY W (OD)
Entity type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:W
Last Name:BOURDAGE
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:PO BOX 888
Mailing Address - Street 2:
Mailing Address - City:WALDPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97394-0888
Mailing Address - Country:US
Mailing Address - Phone:541-563-4100
Mailing Address - Fax:541-563-4468
Practice Address - Street 1:525 NW WILLOW
Practice Address - Street 2:
Practice Address - City:WALDPORT
Practice Address - State:OR
Practice Address - Zip Code:97394-0888
Practice Address - Country:US
Practice Address - Phone:541-563-4100
Practice Address - Fax:541-563-4468
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1177AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR236117Medicaid
OR236117Medicaid
OR139549Medicare PIN
ORT67442Medicare UPIN
ORR0000PGCRXMedicare PIN