Provider Demographics
NPI:1275515918
Name:FERTIG, EVAN JACOB (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:JACOB
Last Name:FERTIG
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 ST
Practice Address - Street 2:SUITE 615
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2958
Practice Address - Country:US
Practice Address - Phone:503-215-8580
Practice Address - Fax:503-215-8585
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0432922084N0400X
ORMD1736872084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001432921Medicaid
NJ0171441Medicaid
OR500689501Medicaid
CT001432921Medicaid
ORR183502Medicare PIN
OR500689501Medicaid
NJ0171441Medicaid