1851557607 NPI number — LAKE OSWEGO FOOT CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851557607 NPI number — LAKE OSWEGO FOOT CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE OSWEGO FOOT CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1851557607
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4000 KRUSE WAY PLACE
Provider Second Line Business Mailing Address:
BLDG 2, STE 220
Provider Business Mailing Address City Name:
LAKE OSWEGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-636-9656
Provider Business Mailing Address Fax Number:
503-636-9657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 KRUSE WAY PLACE
Provider Second Line Business Practice Location Address:
BLDG 2, STE 220
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-636-9656
Provider Business Practice Location Address Fax Number:
503-636-9657
Provider Enumeration Date:
07/31/2008

Additional Information

Authorized Official

Authorized Official Last Name:
YOON
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
503-777-3999

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  DP00338 , 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: 286958 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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