Provider Demographics
NPI:1316178189
Name:AMAVISCA, JOSEPH ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ALBERT
Last Name:AMAVISCA
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 1:19250 SW 65TH AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7745
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:19250 SW 65TH AVE STE 250
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7745
Practice Address - Country:US
Practice Address - Phone:503-808-9213
Practice Address - Fax:971-346-4465
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
ORMD156341207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500672860Medicaid
OR161133OtherNBMC GROUP MEDICAID
OR930635514OtherNBMC GROUP TAX ID FOR BILLING
ORR0000WFBTVOtherNBMC GROUP MEDICARE #
OR500672860Medicaid
ORR164919Medicare PIN