Provider Demographics
NPI:1649312398
Name:IVAN P LAW MD PC
Entity type:Organization
Organization Name:IVAN P LAW MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:PE
Authorized Official - Last Name:LAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-288-5067
Mailing Address - Street 1:2707 NE 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3649
Mailing Address - Country:US
Mailing Address - Phone:503-288-5067
Mailing Address - Fax:503-282-9670
Practice Address - Street 1:2707 NE 33RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3649
Practice Address - Country:US
Practice Address - Phone:503-288-5067
Practice Address - Fax:503-282-9670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10631207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1233709Medicaid
OR041160Medicaid
C94411Medicare UPIN
WAG8808571Medicare PIN
OR041160Medicaid