Provider Demographics
NPI:1932138104
Name:DECASTRO, ENRIQUE M (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:M
Last Name:DECASTRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11750 SW BARNES ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5911
Mailing Address - Country:US
Mailing Address - Phone:503-416-9922
Mailing Address - Fax:503-416-9971
Practice Address - Street 1:11750 SW BARNES ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5911
Practice Address - Country:US
Practice Address - Phone:503-416-9922
Practice Address - Fax:503-416-9971
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD05941207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR047126Medicaid
OR047126Medicaid
ORC94290Medicare UPIN