Provider Demographics
NPI:1134202310
Name:HENDRICKSON, IRENE WINONAH C (MD)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:WINONAH C
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:WINONAH C
Other - Last Name:HENDRICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9205 SW BARNES RD
Practice Address - Street 2:MT2800
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6603
Practice Address - Country:US
Practice Address - Phone:503-216-2621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24727207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR232802Medicaid
ORR156079Medicare PIN
ORR156077Medicare PIN
ORR156080Medicare PIN
I02537Medicare UPIN
OR232802Medicaid
ORR155310Medicare PIN
ORR156078Medicare PIN
ORR160496Medicare PIN
ORR132555Medicare PIN