Basic Information
Provider Information | |||||||||
NPI: | 1013918267 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AUSTIN | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | CHRISTOPHER | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
Address2: | PEDIATRIC UROLOGY CDW-6 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 97239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034944808 | ||||||||
FaxNumber: | 5034944743 | ||||||||
Practice Location | |||||||||
Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
Address2: | PEDIATRIC UROLOGY CDW-6 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 97239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034944808 | ||||||||
FaxNumber: | 5034944743 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2005 | ||||||||
LastUpdateDate: | 12/01/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 34484 | IA | N |   | Allopathic & Osteopathic Physicians | Urology |   | 2088P0231X | MD29351 | OR | Y |   | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
ID Information
ID | Type | State | Issuer | Description | 44934 | 01 | IA | WELLMARK BC/BS | OTHER | 0260976 | 05 | IA |   | MEDICAID |