Provider Demographics
NPI:1952536351
Name:KUROSU, JOE WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:WAYNE
Last Name:KUROSU
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 1:5015 NE 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-6322
Mailing Address - Country:US
Mailing Address - Phone:971-808-9282
Mailing Address - Fax:
Practice Address - Street 1:7545 NE AMBASSADOR PL
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-1367
Practice Address - Country:US
Practice Address - Phone:971-978-4859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD194463207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF06521Medicare UPIN