Provider Demographics
NPI:1437149424
Name:KILTY, JOHN EDMUND (MD PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDMUND
Last Name:KILTY
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 1:19260 SW 65TH AVE
Mailing Address - Street 2:STE 340
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-5701
Mailing Address - Country:US
Mailing Address - Phone:503-691-9777
Mailing Address - Fax:503-692-6736
Practice Address - Street 1:19260 SW 65TH AVE
Practice Address - Street 2:STE 340
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-5701
Practice Address - Country:US
Practice Address - Phone:503-691-9777
Practice Address - Fax:503-692-6736
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20377208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR133935Medicaid
OR000WCJDFMedicare ID - Type Unspecified
OR133935Medicaid