Provider Demographics
NPI:1215188651
Name:LUENGO BASTARRICA, LEISANDRO (MD)
Entity Type:Individual
Prefix:MR
First Name:LEISANDRO
Middle Name:
Last Name:LUENGO BASTARRICA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:LEISANDRO
Other - Middle Name:
Other - Last Name:LUENGO BASTARRICA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3181 SW SAM JACKSON PARK ROAD
Mailing Address - Street 2:OHSU
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:503-494-8211
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:OHSU
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-8211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
OR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator