Provider Demographics
NPI:1073582383
Name:MCKINSTRY, MARK LEO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEO
Last Name:MCKINSTRY
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 1:19875 SW 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8353
Mailing Address - Country:US
Mailing Address - Phone:503-692-7785
Mailing Address - Fax:503-885-1663
Practice Address - Street 1:19875 SW 65TH AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8353
Practice Address - Country:US
Practice Address - Phone:503-692-7785
Practice Address - Fax:503-885-1663
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16271207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028063Medicaid
OR105481Medicare ID - Type Unspecified
OR028063Medicaid