Healthcare Provider Details

I. General information

NPI: 1528293545
Provider Name (Legal Business Name): LOURDES QUINTANILLA-DIECK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
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
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-5674
  • Fax: 503-494-4631
Mailing address:
  • Phone: 503-494-5674
  • Fax: 503-494-4631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberMD173369
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD173369
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: