Basic Information
| Provider Information | |||||||||
| NPI: | 1114153194 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAGGENSTOS | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | ATHELSTAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 847 NE 19TH AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039632801 | ||||||||
| FaxNumber: | 5039632825 | ||||||||
| Practice Location | |||||||||
| Address1: | 9155 SW BARNES RD | ||||||||
| Address2: | SUITE 440 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039358500 | ||||||||
| FaxNumber: | 5039358505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2009 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | MD153961 | OR | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 500635997 | 05 | OR | MEDICAID | 1114153194 | 05 | WA | MEDICAID |