Provider Demographics
NPI:1699814830
Name:QUILES SOO, NITZA (MD)
Entity Type:Individual
Prefix:MRS
First Name:NITZA
Middle Name:
Last Name:QUILES SOO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9555 SW BARNES RD
Mailing Address - Street 2:#270
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225
Mailing Address - Country:US
Mailing Address - Phone:503-297-1025
Mailing Address - Fax:503-297-1043
Practice Address - Street 1:9555 SW BARNES RD
Practice Address - Street 2:#270
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-297-1025
Practice Address - Fax:503-297-1043
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 12560208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE87104OtherPHP
OR021993010OtherBLUE CROSS
OR135230Medicaid
OR931129829A009OtherTRICARE