Provider Demographics
NPI:1851557607
Name:LAKE OSWEGO FOOT CLINIC
Entity type:Organization
Organization Name:LAKE OSWEGO FOOT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:YOON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-777-3999
Mailing Address - Street 1:4000 KRUSE WAY PLACE
Mailing Address - Street 2:BLDG 2, STE 220
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035
Mailing Address - Country:US
Mailing Address - Phone:503-636-9656
Mailing Address - Fax:503-636-9657
Practice Address - Street 1:4000 KRUSE WAY PLACE
Practice Address - Street 2:BLDG 2, STE 220
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035
Practice Address - Country:US
Practice Address - Phone:503-636-9656
Practice Address - Fax:503-636-9657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00338261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286958Medicaid
OR286958Medicaid