Provider Demographics
NPI:1225024052
Name:ANTEZANA, DAVID FERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:FERNANDO
Last Name:ANTEZANA
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 1:5050 NE HOYT ST STE 359
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2983
Practice Address - Country:US
Practice Address - Phone:503-935-8501
Practice Address - Fax:503-935-8506
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24021207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1225024052Medicaid
OR286392Medicaid
140008235OtherRR MEDICARE
H12692Medicare UPIN
OR166918Medicare PIN
140008235OtherRR MEDICARE
OR286392Medicaid