Provider Demographics
NPI:1164509733
Name:GISWOLD, MARY ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:GISWOLD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4030 NE STANTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2957
Mailing Address - Country:US
Mailing Address - Phone:503-281-4213
Mailing Address - Fax:
Practice Address - Street 1:10100 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-571-3099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23643208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery