Provider Demographics
NPI:1104896786
Name:SKOOG, STEVEN JOHN
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:JOHN
Last Name:SKOOG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:CDW6
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-4808
Mailing Address - Fax:503-494-4743
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:CDW6
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-4808
Practice Address - Fax:503-494-4743
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25042208800000X
OR179522088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORB56930Medicare UPIN