Provider Demographics
NPI:1881078426
Name:GRENDAR, JAN (MD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:GRENDAR
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 1:905 NE 47TH AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2226
Mailing Address - Country:US
Mailing Address - Phone:503-215-3258
Mailing Address - Fax:
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:SUITE 6N60
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-215-3258
Practice Address - Fax:503-215-3254
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORFE172129208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery