Provider Demographics
NPI:1356609374
Name:BOLOGNESE, ALEXANDRA CERUTTI (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:CERUTTI
Last Name:BOLOGNESE
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-4314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
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:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-7810
Practice Address - Fax:503-494-5292
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73045204F00000X, 208600000X
ORMD210833208600000X, 204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD210833OtherLICENSE