Provider Demographics
NPI:1124054663
Name:LUU, VIEN THAO (MD)
Entity type:Individual
Prefix:
First Name:VIEN THAO
Middle Name:
Last Name:LUU
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 1:417 SW 117TH AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5924
Practice Address - Country:US
Practice Address - Phone:503-216-9400
Practice Address - Fax:503-216-9499
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150759Medicaid
ORP00298494OtherRR MEDICARE
ORP00298494OtherRR MEDICARE
ORR112721Medicare PIN
ORR112720Medicare PIN
OR150759Medicaid
ORR132311Medicare PIN
ORR136291Medicare PIN
WAG8903711Medicare PIN