Healthcare Provider Details

I. General information

NPI: 1780796326
Provider Name (Legal Business Name): OLEG MAKSIMOV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 NW BURNSIDE RD FL 2
GRESHAM OR
97030-3739
US

IV. Provider business mailing address

689 NW BURNSIDE RD FL 1
GRESHAM OR
97030-3739
US

V. Phone/Fax

Practice location:
  • Phone: 503-382-8106
  • Fax: 503-382-8100
Mailing address:
  • Phone: 503-382-8106
  • Fax: 503-382-8100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD431737
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD28526
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: