Provider Demographics
NPI:1346268158
Name:KANTROWITZ, MICKI A (MD)
Entity Type:Individual
Prefix:
First Name:MICKI
Middle Name:A
Last Name:KANTROWITZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICKI
Other - Middle Name:ALICE
Other - Last Name:KANTROWITZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6410 NE HALSEY ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-4759
Mailing Address - Country:US
Mailing Address - Phone:503-215-2273
Mailing Address - Fax:
Practice Address - Street 1:6410 NE HALSEY ST STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-4759
Practice Address - Country:US
Practice Address - Phone:503-215-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0040152207Q00000X
VA0101258386207Q00000X
ORMD180886207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B86180Medicare UPIN
FL18211Medicare ID - Type Unspecified
FL370802100Medicaid