Provider Demographics
NPI:1275649162
Name:PATILLO, DOMINIC PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:PATRICK
Last Name:PATILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1515 NW 18TH AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2539
Mailing Address - Country:US
Mailing Address - Phone:503-256-5866
Mailing Address - Fax:503-254-0656
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:SUITE 327
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2448
Practice Address - Country:US
Practice Address - Phone:503-256-5866
Practice Address - Fax:503-517-8209
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD151644207XS0106X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery