Provider Demographics
NPI:1992000277
Name:MADIAN, MARCO JAN (LMT)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:JAN
Last Name:MADIAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12069
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-0069
Mailing Address - Country:US
Mailing Address - Phone:503-816-4477
Mailing Address - Fax:
Practice Address - Street 1:2442 SE 101ST AVE
Practice Address - Street 2:STE 206
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3060
Practice Address - Country:US
Practice Address - Phone:503-816-4477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15569247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR93-1118390OtherITIN