Provider Demographics
NPI:1871606293
Name:LAFAYETTE, TRAVIS PACK (OD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:PACK
Last Name:LAFAYETTE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:TRAVIS PACK
Other - Last Name:LAFAYETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:13865 SE 119TH DR
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-7607
Mailing Address - Country:US
Mailing Address - Phone:503-698-3662
Mailing Address - Fax:
Practice Address - Street 1:19500 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5757
Practice Address - Country:US
Practice Address - Phone:503-669-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR 2729T152W00000X
WAWA OD00003720152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist