Provider Demographics
NPI:1629059407
Name:LOWENKOPF, THEODORE J (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:J
Last Name:LOWENKOPF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TED
Other - Middle Name:J
Other - Last Name:LOWENKOPF
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9135 SW BARNES RD
Practice Address - Street 2:STE 461
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6646
Practice Address - Country:US
Practice Address - Phone:503-216-1150
Practice Address - Fax:971-282-0086
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1102692084N0400X
MT373342084N0400X
ORMD222192084N0400X, 2084V0102X
CAG1422992084N0400X
WAMD602174582084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00777837OtherRR MEDICARE
OR130328Medicaid
OR130328Medicaid
ORR192437Medicare PIN
ORP00777837OtherRR MEDICARE
G78688Medicare UPIN
ORR148415Medicare PIN