Provider Demographics
NPI:1083904015
Name:YSUNZA, EDWARD THEODORE IV
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:THEODORE
Last Name:YSUNZA
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21540 NW FRANSON WAY # 2201
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97006-6076
Mailing Address - Country:US
Mailing Address - Phone:503-858-4641
Mailing Address - Fax:
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP170018213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery