Healthcare Provider Details

I. General information

NPI: 1962484824
Provider Name (Legal Business Name): ANTHONY I COLORITO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 NW 18TH AVE SUITE 300
PORTLAND OR
97209-2515
US

IV. Provider business mailing address

1515 NW 18TH AVE SUITE 300
PORTLAND OR
97209-2515
US

V. Phone/Fax

Practice location:
  • Phone: 503-224-8399
  • Fax: 503-224-5661
Mailing address:
  • Phone: 503-224-8399
  • Fax: 503-224-5661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD22621
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: