Basic Information
| Provider Information | |||||||||
| NPI: | 1366634966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATANABE | ||||||||
| FirstName: | MIKI | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 92900 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972920900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032616985 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10123 SE MARKET ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032616985 | ||||||||
| FaxNumber: | 5032616790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 07/30/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 49294 | CO | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 49294 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MT186972 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD165733 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 49294 | 01 | CO | CO LICENSE | OTHER |