Provider Demographics
NPI:1598835688
Name:PORTLAND EAR NOSE & THROAT
Entity Type:Organization
Organization Name:PORTLAND EAR NOSE & THROAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLELAND ZAMUDIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-408-1323
Mailing Address - Street 1:10535 NE GLISAN
Mailing Address - Street 2:#350
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220
Mailing Address - Country:US
Mailing Address - Phone:503-408-1323
Mailing Address - Fax:503-408-4463
Practice Address - Street 1:10535 NE GLISAN
Practice Address - Street 2:#350
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:503-408-1323
Practice Address - Fax:503-408-4463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21133207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151216Medicaid
OR104863Medicare ID - Type Unspecified
F9145Medicare UPIN
OR151216Medicaid