Provider Demographics
NPI:1316924046
Name:KIZZIAR, RONALD (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:KIZZIAR
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 1:545 NE 47TH AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2238
Mailing Address - Country:US
Mailing Address - Phone:503-731-2904
Mailing Address - Fax:
Practice Address - Street 1:545 NE 47TH AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2238
Practice Address - Country:US
Practice Address - Phone:503-731-2904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD213102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8376576Medicaid
OR840126006OtherREGENCE BS/BC
OR226863Medicaid
ORP0058316OtherRR MC
ORR116628Medicare PIN
ORH81437Medicare UPIN
OR226863Medicaid