Provider Demographics
NPI:1790721215
Name:HORACEK, JEFFREY J (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:J
Last Name:HORACEK
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 1:5050 NE HOYT ST
Mailing Address - Street 2:#203
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2991
Mailing Address - Country:US
Mailing Address - Phone:503-230-9224
Mailing Address - Fax:503-230-9201
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:#203
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-230-9224
Practice Address - Fax:503-230-9201
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18532207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR080114Medicaid
OR110164099OtherRR MEDICARE
ORG27763Medicare UPIN
OR080114Medicaid