Provider Demographics
NPI:1093702862
Name:DE GEEST, KOENRAAD (MD)
Entity Type:Individual
Prefix:
First Name:KOENRAAD
Middle Name:
Last Name:DE GEEST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KOEN
Other - Middle Name:
Other - Last Name:DE GEEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:MC:L466
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-418-4500
Mailing Address - Fax:503-494-4473
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:MC:L466
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-418-4500
Practice Address - Fax:503-494-4473
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35280207VX0201X
ORMD162819207VX0201X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA35627OtherWELLMARK BCBS
IA0422592Medicaid
IAI10738Medicare PIN
IAP00159775Medicare PIN
IA35627OtherWELLMARK BCBS