Provider Demographics
NPI:1720220791
Name:EJIASA, OTUODITA E (MD)
Entity Type:Individual
Prefix:
First Name:OTUODITA
Middle Name:E
Last Name:EJIASA
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 1:7320 SW HUNZIKER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2302
Mailing Address - Country:US
Mailing Address - Phone:503-941-3077
Mailing Address - Fax:
Practice Address - Street 1:728 MOLALLA AVE
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2799
Practice Address - Country:US
Practice Address - Phone:503-656-9030
Practice Address - Fax:503-656-9026
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD156940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500652138Medicaid