Provider Demographics
NPI:1417949926
Name:JAN, JAY C P (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:C P
Last Name:JAN
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 1:1130 NW 22ND AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2900
Mailing Address - Country:US
Mailing Address - Phone:503-413-5725
Mailing Address - Fax:503-413-5726
Practice Address - Street 1:1130 NW 22ND AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2900
Practice Address - Country:US
Practice Address - Phone:503-413-5725
Practice Address - Fax:503-413-5726
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24533208600000X
WAMD00047700208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227380Medicaid
WA8376584Medicaid
ORH89753Medicare UPIN
OR116422Medicare ID - Type Unspecified
ORR136177Medicare PIN