Provider Demographics
NPI:1336108208
Name:JOHN, MICHELLE L (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:JOHN
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 1:1414 NE HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24988 SE STARK ST
Practice Address - Street 2:SUITE 220
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8322
Practice Address - Country:US
Practice Address - Phone:503-674-1580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25190207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine