Healthcare Provider Details

I. General information

NPI: 1336130806
Provider Name (Legal Business Name): TODD SHANE CROCENZI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 NE GLISAN ST 6N40
PORTLAND OR
97213-2933
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-5696
  • Fax: 503-215-5695
Mailing address:
  • Phone: 503-215-6494
  • Fax: 503-215-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD26231
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: