Basic Information
| Provider Information | |||||||||
| NPI: | 1346514189 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROLA NETTO | ||||||||
| FirstName: | JOAO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25180 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972980180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037976356 | ||||||||
| FaxNumber: | 5032920346 | ||||||||
| Practice Location | |||||||||
| Address1: | 9205 SW BARNES RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032164830 | ||||||||
| FaxNumber: | 5032920346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2012 | ||||||||
| LastUpdateDate: | 01/12/2018 | ||||||||
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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 | 2085N0700X | MD176837 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | MD176837 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 176837 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085D0003X | MD176837 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging |
ID Information
| ID | Type | State | Issuer | Description | 500655260 | 05 | OR | MEDICAID |