Provider Demographics
NPI:1700912300
Name:SAKON, KEITA (MD)
Entity Type:Individual
Prefix:
First Name:KEITA
Middle Name:
Last Name:SAKON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 OAK ST SE BLDG C
Mailing Address - Street 2:STE 210
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3975
Mailing Address - Country:US
Mailing Address - Phone:503-814-4480
Mailing Address - Fax:503-814-4482
Practice Address - Street 1:875 OAK ST SE BLDG C
Practice Address - Street 2:STE 210
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3975
Practice Address - Country:US
Practice Address - Phone:503-814-4480
Practice Address - Fax:503-814-4482
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV10487173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500027Medicaid
NVV37798Medicare PIN
NV100500027Medicaid