Individual
TU MAI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
2222 NW LOVEJOY ST STE 315, PORTLAND, OR 97210-5101
(503) 413-8018
Mailing address
PO BOX 3777, PORTLAND, OR 97208-3777
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
DO226717
OR
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/17/2021
Last updated
09/05/2025
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