Provider Demographics
NPI:1558322909
Name:NYONATOR, EDEM (MD)
Entity Type:Individual
Prefix:
First Name:EDEM
Middle Name:
Last Name:NYONATOR
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 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:503-257-2500
Mailing Address - Fax:
Practice Address - Street 1:10123 SE MARKET ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2532
Practice Address - Country:US
Practice Address - Phone:503-257-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26162207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR858464008OtherBCBS-SPRINGFIELD
OR858463010OtherBCBS-MEDFORD
ORP00276736OtherRR MEDICARE
OR026826Medicaid
OR838334011OtherBCBS-ROSEBURG
OR858464008OtherBCBS-SPRINGFIELD
OR026826Medicaid