Provider Demographics
NPI:1992392179
Name:COLASURDO, MARCO
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:COLASURDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3042
Mailing Address - Country:US
Mailing Address - Phone:503-494-7660
Mailing Address - Fax:503-494-4258
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3042
Practice Address - Country:US
Practice Address - Phone:503-494-7660
Practice Address - Fax:503-494-4258
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP100702452085N0700X
ORMF2144922085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology