Provider Demographics
NPI:1376519207
Name:GOETZ, HEIDI (MD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:
Last Name:GOETZ
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 1:425 SW ALDERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6449
Mailing Address - Country:US
Mailing Address - Phone:503-292-5624
Mailing Address - Fax:503-297-4714
Practice Address - Street 1:425 SW ALDERIDGE DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6449
Practice Address - Country:US
Practice Address - Phone:503-292-5624
Practice Address - Fax:503-297-4714
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15962207L00000X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR068973Medicaid
WA1051523Medicaid
CAXPY197514Medicaid
AKMD244ORMedicaid
OR050041429OtherRR MEDICARE
MT1376519207Medicaid
A28665Medicare UPIN
WA1051523Medicaid