Basic Information
| Provider Information | |||||||||
| NPI: | 1386610277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICOLOFF | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | DEMETRE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 N GRAHAM ST | ||||||||
| Address2: | SUITE 415 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972271654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133580 | ||||||||
| FaxNumber: | 5034133578 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 N GRAHAM ST | ||||||||
| Address2: | SUITE 415 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972271654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133580 | ||||||||
| FaxNumber: | 5034133578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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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 | 2086S0129X | 18926 | OR | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 226934 | 05 | OR | MEDICAID |