Basic Information
| Provider Information | |||||||||
| NPI: | 1164789079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARON | ||||||||
| FirstName: | DOMINIQUE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3101 JACKSON PARK RD. | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032156494 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3101 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032213424 | ||||||||
| FaxNumber: | 5032213490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2012 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XP3100X | MD195426 | OR | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207X00000X | MD195426 | OR | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.