Provider Demographics
NPI:1962486373
Name:OKAMOTO, PAUL EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:EDWARD
Last Name:OKAMOTO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4038
Mailing Address - Country:US
Mailing Address - Phone:503-224-2225
Mailing Address - Fax:503-222-3883
Practice Address - Street 1:1730 NE 10TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-4038
Practice Address - Country:US
Practice Address - Phone:503-224-2225
Practice Address - Fax:503-222-3883
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR272594111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T67068Medicare UPIN
R103540Medicare ID - Type Unspecified