Provider Demographics
NPI:1619192994
Name:MCAULIFFE, KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MCAULIFFE
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 1:3218 SE 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1824
Mailing Address - Country:US
Mailing Address - Phone:503-771-6996
Mailing Address - Fax:
Practice Address - Street 1:1185 S ELM ST
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3935
Practice Address - Country:US
Practice Address - Phone:503-723-4660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13792207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC94434Medicare UPIN