Provider Demographics
NPI:1659342509
Name:GUBLER, KELLY DEAN (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:DEAN
Last Name:GUBLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N GRAHAM
Mailing Address - Street 2:SUITE #580
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227
Mailing Address - Country:US
Mailing Address - Phone:503-528-0704
Mailing Address - Fax:503-528-0708
Practice Address - Street 1:501 N GRAHAM
Practice Address - Street 2:SUITE #580
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227
Practice Address - Country:US
Practice Address - Phone:503-528-0704
Practice Address - Fax:503-528-0708
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO23244208600000X
CA20A4923208600000X
WAOP00000951208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287256Medicaid
F32565Medicare UPIN
OR109956Medicare ID - Type Unspecified