1013971837 NPI number — DR. KENNETH PAUL MELVIN MD

Table of content: DR. KENNETH PAUL MELVIN MD (NPI 1013971837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013971837 NPI number — DR. KENNETH PAUL MELVIN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELVIN
Provider First Name:
KENNETH
Provider Middle Name:
PAUL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013971837
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6975 SW SANDBURG ST
Provider Second Line Business Mailing Address:
SUITE 190
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-8073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-639-0600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4035 MERCANTILE DR
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
LAKE OSWEGO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97035-2546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-203-1177
Provider Business Practice Location Address Fax Number:
503-203-1178
Provider Enumeration Date:
04/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD 24232 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 269812 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD24232 . This is a "MEDICAL LICENCE NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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