Provider Demographics
NPI:1558331363
Name:IZENBERG, SETH DAVID (MD)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:DAVID
Last Name:IZENBERG
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 1:501 N GRAHAM
Mailing Address - Street 2:SUITE #580
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227
Mailing Address - Country:US
Mailing Address - Phone:503-528-0704
Mailing Address - Fax:503-528-0708
Practice Address - Street 1:501 N GRAHAM
Practice Address - Street 2:SUITE #580
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227
Practice Address - Country:US
Practice Address - Phone:503-528-0704
Practice Address - Fax:503-528-0708
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21051208600000X
TX014019208600000X
AL00015457208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287738Medicaid
OR109142Medicare ID - Type Unspecified
OR287738Medicaid