Provider Demographics
NPI:1659320471
Name:HYDE, JASON KARL (MD)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:KARL
Last Name:HYDE
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 4207
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4207
Mailing Address - Country:US
Mailing Address - Phone:503-413-6121
Mailing Address - Fax:503-241-5037
Practice Address - Street 1:202 NW 20TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1907
Practice Address - Country:US
Practice Address - Phone:503-274-7128
Practice Address - Fax:503-241-5037
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046624207ZP0102X
OR55950207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8536674Medicaid
ORR141793Medicare PIN
WAG8873802Medicare PIN