Provider Demographics
NPI:1104000496
Name:GHETIE, CRISTIAN NICU (MD)
Entity Type:Individual
Prefix:
First Name:CRISTIAN
Middle Name:NICU
Last Name:GHETIE
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9205 SW BARNES RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6603
Practice Address - Country:US
Practice Address - Phone:503-216-2906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD163113207R00000X, 208M00000X
SC32187207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC321876Medicaid
OR500660133Medicaid
NC5914192Medicaid
SCP00781600OtherRAILROAD MEDICARE
ORP01247664OtherRR MEDICARE - PH&S - OREGON (PMG)
ORP01247664OtherRR MEDICARE - PH&S - OREGON (PMG)
SCP00781600OtherRAILROAD MEDICARE
SC321876Medicaid