Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | D10861 | OR |
Y | 213EG0000X | General Practice | D10861 | OR |
NPI | 1003200122 |
---|---|
Provider Name | Dr. Michael J Dienberg |
First Address | Portland, OR 97239-3011 |
Second Address | Portland, OR 97239 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2015 |
Last Update Date | 27/07/2018 |