=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255678439
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL ALEXANDER ANANYEV D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2013
-----------------------------------------------------
Last Update Date | 01/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16463 BOONES FERRY RD STE 300
-----------------------------------------------------
City | LAKE OSWEGO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97035-4376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-658-9351
-----------------------------------------------------
Fax | 541-708-5934
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4037
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97208-4037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 541-708-5934
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | DO166843
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------