Provider Demographics
NPI:1497790141
Name:WEICK, WALTER JOE (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:JOE
Last Name:WEICK
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 1:300 N GRAHAM ST
Mailing Address - Street 2:SUITE #100
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1683
Mailing Address - Country:US
Mailing Address - Phone:503-413-1122
Mailing Address - Fax:503-413-4238
Practice Address - Street 1:300 N GRAHAM ST
Practice Address - Street 2:SUITE #100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1683
Practice Address - Country:US
Practice Address - Phone:503-413-1122
Practice Address - Fax:503-413-4238
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16818207VM0101X
WAMD00045734207VM0101X
CAA23031207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR011192Medicaid
ORC94057Medicare UPIN
OR011192Medicaid