Provider Demographics
NPI:1447216189
Name:ENLOE, STEPHEN ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ROBERT
Last Name:ENLOE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16463 BOONES FERRY RD # 300
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4259
Mailing Address - Country:US
Mailing Address - Phone:503-635-6256
Mailing Address - Fax:503-636-9604
Practice Address - Street 1:16463 BOONES FERRY RD # 300
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-4259
Practice Address - Country:US
Practice Address - Phone:503-635-6256
Practice Address - Fax:503-636-9604
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2012-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9364207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR58-055988Medicaid
OR58-055988Medicaid
C92586Medicare UPIN