Basic Information
| Provider Information | |||||||||
| NPI: | 1295787059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORIMOTO | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25184 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032929108 | ||||||||
| FaxNumber: | 5032920346 | ||||||||
| Practice Location | |||||||||
| Address1: | 9205 SW BARNES RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032929108 | ||||||||
| FaxNumber: | 5032920346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 01/15/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 26620 | OR | N | Other Service Providers | Specialist | 2085R0202X | 26620 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | OR | MEDICAID |