Provider Demographics
NPI:1487844320
Name:COLVILLE, CHRISTOPHER M (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:M
Last Name:COLVILLE
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:PO BOX 2040
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2040
Mailing Address - Country:US
Mailing Address - Phone:503-299-9906
Mailing Address - Fax:503-225-9002
Practice Address - Street 1:120 NW 14TH AVE
Practice Address - Street 2:STE 300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2643
Practice Address - Country:US
Practice Address - Phone:503-299-9906
Practice Address - Fax:503-225-9002
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00047745207L00000X
ORMD28252207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR024496Medicaid
WA8504466Medicaid
ORP00697891OtherRR MEDICARE
OR142674Medicare PIN