Basic Information
| Provider Information | |||||||||
| NPI: | 1699727917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORDOVA | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 CENTERPOINTE DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970358653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037972268 | ||||||||
| FaxNumber: | 5032348227 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 MOLALLA AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970453788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036565273 | ||||||||
| FaxNumber: | 5036504828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 02/14/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/28/2011 | ||||||||
| NPIReactivationDate: | 02/14/2012 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD09119 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 238659 | 05 | OR | MEDICAID | 110154334 | 01 | RR PIN NUMBER | OTHER |