Provider Demographics
NPI:1336188358
Name:STOLL, MICHAEL E (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:STOLL
Suffix:
Gender:M
Credentials:MD
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 66500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97290-6500
Mailing Address - Country:US
Mailing Address - Phone:503-657-8663
Mailing Address - Fax:503-723-3180
Practice Address - Street 1:233 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4106
Practice Address - Country:US
Practice Address - Phone:503-253-1105
Practice Address - Fax:503-535-8399
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD144932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR044941Medicaid
WA8134959Medicaid
OR114189Medicare ID - Type Unspecified
WAAB20518Medicare ID - Type Unspecified
OR103014Medicare ID - Type Unspecified
WA8134959Medicaid
OR044941Medicaid
OR103005Medicare ID - Type Unspecified