Provider Demographics
NPI:1871562892
Name:WALCZYK, MICHAEL H (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:WALCZYK
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:PO BOX 4037
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4037
Mailing Address - Country:US
Mailing Address - Phone:503-413-4048
Mailing Address - Fax:503-413-2910
Practice Address - Street 1:1130 NW 22ND AVE STE 400
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2971
Practice Address - Country:US
Practice Address - Phone:503-413-6722
Practice Address - Fax:503-413-6563
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA23874207RN0300X
HIMD19676207RN0300X
OR13217207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR147116Medicaid
WA1029586Medicaid
OR147116Medicaid
WA1029586Medicaid