Basic Information
| Provider Information | |||||||||
| NPI: | 1184693020 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONETA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4008 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033722740 | ||||||||
| FaxNumber: | 5033722755 | ||||||||
| Practice Location | |||||||||
| Address1: | 11782 SW BARNES RD | ||||||||
| Address2: | BLDG C #200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039064300 | ||||||||
| FaxNumber: | 5039064333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 03/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD18011 | OR | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 051453 | 05 | OR | MEDICAID | 840285000 | 01 | OR | REGENCE BCBSO | OTHER |