Provider Demographics
NPI:1699727917
Name:CORDOVA, LEE (MD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:CORDOVA
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 1:6 CENTERPOINTE DR
Mailing Address - Street 2:STE 200
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-8653
Mailing Address - Country:US
Mailing Address - Phone:503-797-2268
Mailing Address - Fax:503-234-8227
Practice Address - Street 1:1001 MOLALLA AVE
Practice Address - Street 2:STE 100
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-3788
Practice Address - Country:US
Practice Address - Phone:503-656-5273
Practice Address - Fax:503-650-4828
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2012-02-14
Deactivation Date:2011-12-28
Deactivation Code:
Reactivation Date:2012-02-14
Provider Licenses
StateLicense IDTaxonomies
ORMD09119207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR238659Medicaid
110154334OtherRR PIN NUMBER
110154334OtherRR PIN NUMBER
OR112396Medicare PIN