Provider Demographics
NPI:1639120314
Name:MANTHEY, RICHARD C (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:C
Last Name:MANTHEY
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:1321 NE 99TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9436
Practice Address - Country:US
Practice Address - Phone:503-215-9900
Practice Address - Fax:503-215-4025
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.018258207P00000X
ORMD28549207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500610065Medicaid
ORMD28549OtherLICENSE
ORP00893292OtherRR MEDICARE - PHS
ORR150689Medicare PIN
ORMD28549OtherLICENSE
ORR162336Medicare PIN
OR500610065Medicaid
ORR161973Medicare PIN
ORR162944Medicare PIN