Provider Demographics
NPI:1356300925
Name:MICHAEL D MONETA MD PC
Entity Type:Organization
Organization Name:MICHAEL D MONETA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:MONETA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-297-7223
Mailing Address - Street 1:PO BOX 4008
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4008
Mailing Address - Country:US
Mailing Address - Phone:503-372-2740
Mailing Address - Fax:503-372-2755
Practice Address - Street 1:11782 SW BARNES RD
Practice Address - Street 2:BLDG C #200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-906-4300
Practice Address - Fax:503-906-4333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18011207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR121649Medicare PIN