Provider Demographics
NPI:1679682439
Name:MICHAEL, ELLIOT (DPM)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 SE OAK STREET SUITE 1A
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4240
Mailing Address - Country:US
Mailing Address - Phone:503-648-2200
Mailing Address - Fax:503-693-1004
Practice Address - Street 1:862 SE OAK ST STE 1A
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4240
Practice Address - Country:US
Practice Address - Phone:503-648-2200
Practice Address - Fax:503-693-1004
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00179213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0950720001OtherDMERC
OR162131Medicaid
OR0977970001OtherDMERC
OR0977970001OtherDMERC
OR0977970001OtherDMERC
T67916Medicare UPIN
OR0950720001OtherDMERC
ORR139833Medicare PIN