Provider Demographics
NPI:1003845447
Name:JANZEN, TIMOTHY P (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:P
Last Name:JANZEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10803 SE CHERRY BLOSSOM DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-3107
Mailing Address - Country:US
Mailing Address - Phone:503-261-7200
Mailing Address - Fax:503-261-7249
Practice Address - Street 1:10803 SE CHERRY BLOSSOM DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3107
Practice Address - Country:US
Practice Address - Phone:503-261-7200
Practice Address - Fax:503-261-7249
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR430120810002OtherPACIFICARE
OR003350006OtherBC/BS
OR011549Medicaid
OR430120810002OtherPACIFICARE
OR011549Medicaid