Provider Demographics
NPI:1386610277
Name:NICOLOFF, ALEXANDER DEMETRE (MD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:DEMETRE
Last Name:NICOLOFF
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 1:501 N GRAHAM ST
Mailing Address - Street 2:SUITE 415
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1654
Mailing Address - Country:US
Mailing Address - Phone:503-413-3580
Mailing Address - Fax:503-413-3578
Practice Address - Street 1:501 N GRAHAM ST
Practice Address - Street 2:SUITE 415
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1654
Practice Address - Country:US
Practice Address - Phone:503-413-3580
Practice Address - Fax:503-413-3578
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR189262086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR226934Medicaid
OR226934Medicaid
ORH78932Medicare UPIN