Provider Demographics
NPI:1760665723
Name:RICHARD, JACOB RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:RAYMOND
Last Name:RICHARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:5050 NE HOYT ST STE 514
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2984
Practice Address - Country:US
Practice Address - Phone:503-488-2323
Practice Address - Fax:503-488-2340
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD151070208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500622821Medicaid
WA1760665723Medicaid
OR500622821Medicaid