Provider Demographics
NPI:1053314633
Name:SOO, EDWARD WEILIE (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:WEILIE
Last Name:SOO
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 1:5050 NE HOYT ST
Mailing Address - Street 2:STE 256
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2982
Mailing Address - Country:US
Mailing Address - Phone:503-239-7767
Mailing Address - Fax:503-215-6897
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:STE 256
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2982
Practice Address - Country:US
Practice Address - Phone:503-239-7767
Practice Address - Fax:503-215-6897
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21475207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130057Medicaid
WA1001220Medicaid
WAG8889294Medicare PIN
OR105531Medicare PIN
ORF46212Medicare UPIN