Provider Demographics
NPI:1306075692
Name:RAZZAK, ANTHONY ANWAR (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:ANWAR
Last Name:RAZZAK
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 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:1111 NE 99TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9428
Practice Address - Country:US
Practice Address - Phone:503-963-2707
Practice Address - Fax:503-963-2802
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD176431207RG0100X, 207RG0100X
MN53158207R00000X
PAMT201086207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500708645Medicaid
WA2046313Medicaid
ORP01761299Medicare PIN
OR500708645Medicaid
MN110013594Medicare PIN