Basic Information
| Provider Information | |||||||||
| NPI: | 1558331363 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IZENBERG | ||||||||
| FirstName: | SETH | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 N GRAHAM | ||||||||
| Address2: | SUITE #580 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035280704 | ||||||||
| FaxNumber: | 5035280708 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 N GRAHAM | ||||||||
| Address2: | SUITE #580 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035280704 | ||||||||
| FaxNumber: | 5035280708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD21051 | OR | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 014019 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 00015457 | AL | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 287738 | 05 | OR | MEDICAID |