Provider Demographics
NPI:1588686422
Name:LAIRSON, EDWARD J (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:LAIRSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11782 SW BARNES RD
Mailing Address - Street 2:STE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5914
Mailing Address - Country:US
Mailing Address - Phone:503-214-5200
Mailing Address - Fax:503-906-6613
Practice Address - Street 1:11782 SW BARNES RD
Practice Address - Street 2:STE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5914
Practice Address - Country:US
Practice Address - Phone:503-214-5200
Practice Address - Fax:503-906-6613
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD24366208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD24366OtherOREGON MEDICAL LICENSE
OR227038Medicaid
OR227038Medicaid