Basic Information
| Provider Information | |||||||||
| NPI: | 1750771762 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LANDMARK MEDICAL OF OREGON PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7755 CENTER AVE | ||||||||
| Address2: | #630 | ||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926473007 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5933 NE WIN SIVERS DR STE 305 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972209106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034205852 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2015 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | LE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5034205852 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD170188 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.