Provider Demographics
NPI:1063657328
Name:RONTAL, ANDREW DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:DAVID
Last Name:RONTAL
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5050 NE HOYT
Practice Address - Street 2:SUITE 315
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2982
Practice Address - Country:US
Practice Address - Phone:503-215-8580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-15
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT398572084N0400X
AK1086492084N0400X
WAMD604785212084N0400X
CAA1408792084N0400X
ORMD1598452084N0400X, 2084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01355678OtherRR MEDICARE (PH&S)-PMG
OR500653063Medicaid
ORR192441Medicare PIN
ORR170294Medicare PIN
ORP01355678OtherRR MEDICARE (PH&S)-PMG
OR500653063Medicaid