Provider Demographics
NPI:1245222371
Name:GOSLIN, KIMBERLY LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LOUISE
Last Name:GOSLIN
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: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:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 315
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2982
Practice Address - Country:US
Practice Address - Phone:503-215-8580
Practice Address - Fax:503-215-8585
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD213712084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276817Medicaid
WA8230369Medicaid
OR276817Medicaid
OR143498Medicare PIN
ORR167426Medicare PIN
ORG73468Medicare UPIN
105548Medicare PIN