Provider Demographics
NPI:1366472623
Name:CHOE, MARIETTA H (MD)
Entity Type:Individual
Prefix:
First Name:MARIETTA
Middle Name:H
Last Name:CHOE
Suffix:
Gender:F
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 1:4104 SE 82ND AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-2954
Practice Address - Country:US
Practice Address - Phone:503-215-9850
Practice Address - Fax:503-215-9855
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20011207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00250304OtherRR MEDICARE
OR135229Medicaid
ORP00250304OtherRR MEDICARE
ORR130091Medicare PIN