Basic Information
| Provider Information | |||||||||
| NPI: | 1801802392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZENONIANI | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 CENTERPOINTE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970358660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037972273 | ||||||||
| FaxNumber: | 5032348155 | ||||||||
| Practice Location | |||||||||
| Address1: | 1185 SOUTH ELM ST | ||||||||
| Address2: | |||||||||
| City: | CANBY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037234660 | ||||||||
| FaxNumber: | 5032666649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 09/29/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD26839 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | MD26839 | OR | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 240159 | 05 | OR | MEDICAID |