Provider Demographics
NPI:1902192396
Name:DUSSEL, JOHN NOEL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:NOEL
Last Name:DUSSEL
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 1:80 SEYMOUR ST
Mailing Address - Street 2:C/O HERMA JOHNSON
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3315
Mailing Address - Country:US
Mailing Address - Phone:860-972-2840
Mailing Address - Fax:
Practice Address - Street 1:9155 SW BARNES RD STE 321
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-292-0070
Practice Address - Fax:503-292-7731
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1887682086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR222469Medicaid