Provider Demographics
NPI:1841366317
Name:MORITA, LLOYD TETSUO (MD)
Entity type:Individual
Prefix:
First Name:LLOYD
Middle Name:TETSUO
Last Name:MORITA
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 1:1002 N BOONES FERRY RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-9602
Mailing Address - Country:US
Mailing Address - Phone:503-981-9526
Mailing Address - Fax:503-982-3814
Practice Address - Street 1:1002 N BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-9602
Practice Address - Country:US
Practice Address - Phone:503-981-9526
Practice Address - Fax:503-982-3814
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMDO8923207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR125799Medicaid
WA8504037Medicaid
OR001 373 000OtherBCBS
WA8870856Medicare PIN
OR001 373 000OtherBCBS
OR140606Medicare PIN
OR141438Medicare PIN
OR125799Medicaid