Provider Demographics
NPI:1407871163
Name:EKSTROM, JON E (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:E
Last Name:EKSTROM
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:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-0053
Mailing Address - Country:US
Mailing Address - Phone:541-687-7134
Mailing Address - Fax:541-687-7135
Practice Address - Street 1:1255 HILYARD STREET
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-687-7134
Practice Address - Fax:541-687-7135
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD159092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8296725Medicaid
OR081315Medicaid
AKMD5427RMedicaid
AKMD893ORMedicaid
AK161116Medicare PIN
AKMD5427RMedicaid
OR00WCPGHCMedicare PIN
WA8296725Medicaid
OR00WCBDCKMedicare ID - Type Unspecified
OR300032390Medicare PIN
OR135699Medicare PIN
OR00WCBDCKMedicare PIN