Provider Demographics
NPI:1619930237
Name:MAYOCK, ELLEN KYTE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:KYTE
Last Name:MAYOCK
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 1:18010 MCEWAN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-7868
Mailing Address - Country:US
Mailing Address - Phone:503-525-7500
Mailing Address - Fax:503-525-7501
Practice Address - Street 1:18010 MCEWAN RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-7868
Practice Address - Country:US
Practice Address - Phone:503-525-7500
Practice Address - Fax:503-525-7501
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19822207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
R0000BLCDQMedicare ID - Type Unspecified
G37188Medicare UPIN