Provider Demographics
NPI:1558487116
Name:OXENTENKO, MICHAEL II
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:OXENTENKO
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43131 SE MUSIC CAMP RD
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-8463
Mailing Address - Country:US
Mailing Address - Phone:503-665-1151
Mailing Address - Fax:503-669-1986
Practice Address - Street 1:5905 SE POWELL VALLEY RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-1919
Practice Address - Country:US
Practice Address - Phone:503-665-1151
Practice Address - Fax:503-669-1986
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1040225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR025176Medicaid