1275649162 NPI number — DR. DOMINIC PATRICK PATILLO MD

Table of content: DR. DOMINIC PATRICK PATILLO MD (NPI 1275649162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275649162 NPI number — DR. DOMINIC PATRICK PATILLO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATILLO
Provider First Name:
DOMINIC
Provider Middle Name:
PATRICK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275649162
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17355 LOWER BOONES FERRY RD
Provider Second Line Business Mailing Address:
STE 100A
Provider Business Mailing Address City Name:
LAKE OSWEGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97035-2839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-256-5866
Provider Business Mailing Address Fax Number:
503-254-0656

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17355 LOWER BOONES FERRY RD
Provider Second Line Business Practice Location Address:
STE 100A
Provider Business Practice Location Address City Name:
LAKE OSWEGO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97035-2839
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-256-5866
Provider Business Practice Location Address Fax Number:
503-254-0656
Provider Enumeration Date:
08/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207XS0106X , with the licence number:  MD151644 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: MD151644 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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