Basic Information
| Provider Information | |||||||||
| NPI: | 1982022778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOETHE | ||||||||
| FirstName: | YILUN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LI | ||||||||
| OtherFirstName: | YILUN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034947660 | ||||||||
| FaxNumber: | 5034944258 | ||||||||
| Practice Location | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034947660 | ||||||||
| FaxNumber: | 5034944258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2014 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD198180 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | A140909 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | ME1377865 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0204X | MD198180 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.