Provider Demographics
NPI:1386647147
Name:KALISIAK, ANGELA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:
Last Name:KALISIAK
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 1:265 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1800
Mailing Address - Country:US
Mailing Address - Phone:503-280-1223
Mailing Address - Fax:503-528-5252
Practice Address - Street 1:265 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1800
Practice Address - Country:US
Practice Address - Phone:503-280-1223
Practice Address - Fax:503-528-5252
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17578207RH0003X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR040886Medicaid
WA1009145Medicaid
OR040886Medicaid
WAG8890293Medicare PIN
ORR153073Medicare PIN