Healthcare Provider Details

I. General information

NPI: 1295260016
Provider Name (Legal Business Name): JONATHAN MICHAEL KRASINKIEWICZ MB BCH BAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2017
Last Update Date: 07/01/2023
Certification Date: 07/01/2023
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: 503-494-8023
  • Fax: 503-494-8898
Mailing address:
  • Phone: 503-494-8023
  • Fax: 503-494-8898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD215246
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number01083902A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberMD215246
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: