Provider Demographics
NPI:1164455606
Name:DAVID J. OGLE, MD
Entity Type:Organization
Organization Name:DAVID J. OGLE, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:OGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-261-0966
Mailing Address - Street 1:10748 NE HALSEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3961
Mailing Address - Country:US
Mailing Address - Phone:503-261-0966
Mailing Address - Fax:503-252-2691
Practice Address - Street 1:10748 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3961
Practice Address - Country:US
Practice Address - Phone:503-261-0966
Practice Address - Fax:503-252-2691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20318207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR114710Medicare ID - Type Unspecified
ORG38499Medicare UPIN