1487703450 NPI number — DR. LEON BRUCE MARSHALL D.O .

Table of content: DR. LEON BRUCE MARSHALL D.O . (NPI 1487703450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487703450 NPI number — DR. LEON BRUCE MARSHALL D.O .

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARSHALL
Provider First Name:
LEON
Provider Middle Name:
BRUCE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O .
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARSHALL
Provider Other First Name:
LEE
Provider Other Middle Name:
BRUCE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1487703450
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
847 NE 19TH AVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97232-2684
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-963-2801
Provider Business Mailing Address Fax Number:
503-963-2825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1040 NW 22ND AVE
Provider Second Line Business Practice Location Address:
SUITE 420
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210-3057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-488-2424
Provider Business Practice Location Address Fax Number:
503-229-7105
Provider Enumeration Date:
01/09/2007

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: 2084N0400X , with the licence number:  5101010950 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: DO29055 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00141408 . This is a "PALMETTO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 500628636 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1587703450 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4507651 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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