Provider Demographics
NPI:1487703450
Name:MARSHALL, LEON BRUCE (DO )
Entity type:Individual
Prefix:DR
First Name:LEON
Middle Name:BRUCE
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:BRUCE
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
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 1:1040 NW 22ND AVE
Practice Address - Street 2:SUITE 420
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3057
Practice Address - Country:US
Practice Address - Phone:503-488-2424
Practice Address - Fax:503-229-7105
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010109502084N0400X
ORDO290552084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00141408OtherPALMETTO
OR500628636Medicaid
WA1587703450Medicaid
MI4507651Medicaid
ON94780Medicare ID - Type UnspecifiedPART B
OR157550Medicare PIN
OR500628636Medicaid