Provider Demographics
NPI:1689653412
Name:METZGER, MARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:METZGER
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 1:10000 SE MAIN ST
Mailing Address - Street 2:STE 327
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2448
Mailing Address - Country:US
Mailing Address - Phone:503-256-5866
Mailing Address - Fax:503-254-0656
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:STE 327
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2448
Practice Address - Country:US
Practice Address - Phone:503-256-5866
Practice Address - Fax:503-254-0656
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23691174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286838Medicaid
OR6249600001Medicare NSC
OR286838Medicaid
ORR112767Medicare PIN