Provider Demographics
NPI:1770928558
Name:DE LUCCA, ALEXIS B (MD)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:B
Last Name:DE LUCCA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:B
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:421 SW OAK ST
Mailing Address - Street 2:STE. 210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:2020 SE 182ND AVENUE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:503-988-5400
Practice Address - Fax:503-988-5668
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD175758207Q00000X
OR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096511Medicaid
OR022959Medicaid
OR096511Medicaid