Basic Information
| Provider Information | |||||||||
| NPI: | 1811019383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLLOCK | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 488 | ||||||||
| Address2: | |||||||||
| City: | TUALATIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970620488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052863826 | ||||||||
| FaxNumber: | 8052216843 | ||||||||
| Practice Location | |||||||||
| Address1: | 19300 SW 65TH AVE | ||||||||
| Address2: | |||||||||
| City: | TUALATIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970627706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036921212 | ||||||||
| FaxNumber: | 5036925307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | MD27981 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0700X | 200501952 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 200501952 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD27981 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 199207 | 01 | MEDOST | OTHER | 242329 | 05 | OR | MEDICAID | Q01952 | 05 | SC | MEDICAID | 1811019383 | 05 | VA | MEDICAID | 5906697 | 05 | NC | MEDICAID | 810604 | 01 | PARTNERS | OTHER | 3810009023 | 05 | WV | MEDICAID | 145JE | 01 | BCBS | OTHER | 9347081 | 01 | AETNA | OTHER |