Provider Demographics
NPI:1417041989
Name:KONKOL, RICHARD J (MD PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:KONKOL
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 N. INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227
Mailing Address - Country:US
Mailing Address - Phone:503-331-5040
Mailing Address - Fax:503-331-5044
Practice Address - Street 1:3550 NORTH INTERSTATE AVE
Practice Address - Street 2:MEDICAL OFFICE EAST
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1097
Practice Address - Country:US
Practice Address - Phone:503-331-5040
Practice Address - Fax:503-331-5044
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD180392084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology