Basic Information
| Provider Information | |||||||||
| NPI: | 1306006457 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LA ROCHELLE | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3303 SW BOND AVE | ||||||||
| Address2: | CH10U | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033461500 | ||||||||
| FaxNumber: | 5033461501 | ||||||||
| Practice Location | |||||||||
| Address1: | 3303 SW BOND AVE | ||||||||
| Address2: | CH10U | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033461500 | ||||||||
| FaxNumber: | 5033461501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2008 | ||||||||
| LastUpdateDate: | 09/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 126296 | OR | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0A1002960 | 05 | CA | MEDICAID |