Provider Demographics
NPI:1386693588
Name:NILAVER, GAJANAN (MD)
Entity type:Individual
Prefix:
First Name:GAJANAN
Middle Name:
Last Name:NILAVER
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: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 1:10202 SE 32ND AVE
Practice Address - Street 2:SUITE 703
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97222-3610
Practice Address - Country:US
Practice Address - Phone:503-513-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14509207R00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00479379OtherRR MEDICARE
OR130708Medicaid
ORP00479379OtherRR MEDICARE
ORB58774Medicare UPIN
ORR109160Medicare PIN
OR0000BHTVBMedicare ID - Type Unspecified