Provider Demographics
NPI:1033145222
Name:LACAYANGA, IMELDA P (MD)
Entity type:Individual
Prefix:
First Name:IMELDA
Middle Name:P
Last Name:LACAYANGA
Suffix:
Gender:F
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9427 SW BARNES RD
Practice Address - Street 2:SUITE 396
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6652
Practice Address - Country:US
Practice Address - Phone:503-216-6550
Practice Address - Fax:503-216-6575
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19170208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067546Medicaid
F50350Medicare UPIN
ORR175274Medicare PIN
ORR175273Medicare PIN
OR067546Medicaid