Provider Demographics
NPI:1487605739
Name:WILTRAKIS, MARK G (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:WILTRAKIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 SE BASELINE ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4149
Mailing Address - Country:US
Mailing Address - Phone:503-648-9591
Mailing Address - Fax:503-648-3872
Practice Address - Street 1:527 SE BASELINE ST
Practice Address - Street 2:SUITE E
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4149
Practice Address - Country:US
Practice Address - Phone:503-648-9591
Practice Address - Fax:503-648-3872
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10754174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR236703Medicaid
ORC94095Medicare UPIN
OR106496Medicare ID - Type Unspecified