Healthcare Provider Details

I. General information

NPI: 1457366965
Provider Name (Legal Business Name): MICHAEL FLYNN BONAZZOLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD MAIL CODE OP04
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 503-418-2070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD11860
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier243994
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier8498701
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: