Provider Demographics
NPI:1124010673
Name:KIYASU, PHILLIP K (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:K
Last Name:KIYASU
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 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:1111 NE 99TH AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9428
Practice Address - Country:US
Practice Address - Phone:503-963-2707
Practice Address - Fax:503-963-2802
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60293921207RG0100X
ORMD18844207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR065607Medicaid
WA8206922Medicaid
OR115844Medicare PIN
OR109983Medicare ID - Type Unspecified
OR065607Medicaid
WA8912749Medicare PIN