Basic Information
| Provider Information | |||||||||
| NPI: | 1508200346 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | METZLER | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033461500 | ||||||||
| FaxNumber: | 5033461501 | ||||||||
| Practice Location | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033461500 | ||||||||
| FaxNumber: | 5033461501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2013 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD60938545 | WA | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | MD199355 | OR | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1508200346 | 05 | WA | MEDICAID |