Healthcare Provider Details

I. General information

NPI: 1376205278
Provider Name (Legal Business Name): MARSHALL ALBERT CANIZALEZ AU.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24076 SE STARK ST STE 230
GRESHAM OR
97030-3385
US

IV. Provider business mailing address

847 NE 19TH AVE STE 300
PORTLAND OR
97232-2686
US

V. Phone/Fax

Practice location:
  • Phone: 503-488-2600
  • Fax: 503-465-5468
Mailing address:
  • Phone: 503-963-2801
  • Fax: 503-963-2825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147001852
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number31054
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: