Provider Demographics
NPI:1326192972
Name:KULLBERG, PATRICIA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:ANN
Last Name:KULLBERG
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 1:421 SW OAK ST
Mailing Address - Street 2:210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-5140
Mailing Address - Fax:503-988-4098
Practice Address - Street 1:426 SW STARK ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-2347
Practice Address - Country:US
Practice Address - Phone:503-988-5140
Practice Address - Fax:503-988-5180
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13823207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORA08214Medicare UPIN
OR08WCJHTAMedicare ID - Type Unspecified