Provider Demographics
NPI:1548253602
Name:URBA, WALTER JOHN (MD, PHD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:JOHN
Last Name:URBA
Suffix:
Gender:M
Credentials:MD, PHD
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:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:6N40
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213
Practice Address - Country:US
Practice Address - Phone:503-215-5696
Practice Address - Fax:503-215-5695
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18449207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1082296Medicaid
OR056023Medicaid
ORR143716Medicare PIN
OR056023Medicaid