Provider Demographics
NPI:1275628166
Name:KOEKKOEK, DOUGLAS A (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:KOEKKOEK
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:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:STE BG05
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-215-2393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16043207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR110082876OtherRR MEDICARE - PH&S - OREGON (PMG)
OR046453Medicaid
OR110082876OtherRR MEDICARE - PH&S - OREGON (PMG)
ORF22560Medicare UPIN
ORR136398Medicare PIN
ORR137364Medicare PIN
OR046453Medicaid