Healthcare Provider Details

I. General information

NPI: 1316262108
Provider Name (Legal Business Name): JONATHAN CARNELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 NE HOYT ST STE 625
PORTLAND OR
97213-2991
US

IV. Provider business mailing address

5050 NE HOYT ST STE 625
PORTLAND OR
97213-2991
US

V. Phone/Fax

Practice location:
  • Phone: 503-731-2900
  • Fax:
Mailing address:
  • Phone: 503-731-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberMD.60550687
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: