Basic Information
| Provider Information | |||||||||
| NPI: | 1336130806 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROCENZI | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | SHANE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3158 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032156494 | ||||||||
| FaxNumber: | 5032156644 | ||||||||
| Practice Location | |||||||||
| Address1: | 4805 NE GLISAN ST | ||||||||
| Address2: | 6N40 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972132933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032155696 | ||||||||
| FaxNumber: | 5032155695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 10/29/2008 | ||||||||
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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 | 207RX0202X | MD26231 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 027918 | 05 | OR | MEDICAID |