Provider Demographics
NPI:1245213834
Name:CARLYLE, MARNI S (MD)
Entity Type:Individual
Prefix:
First Name:MARNI
Middle Name:S
Last Name:CARLYLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARNI
Other - Middle Name:
Other - Last Name:KWIECIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7650 SW BEVELAND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8692
Mailing Address - Country:US
Mailing Address - Phone:503-855-1620
Mailing Address - Fax:503-840-3299
Practice Address - Street 1:9701 SW BARNES RD
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6772
Practice Address - Country:US
Practice Address - Phone:503-734-3700
Practice Address - Fax:503-473-8462
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 23573207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286803Medicaid
ORR113183OtherMEDICARE PTAN
ORR113183OtherMEDICARE PTAN