Provider Demographics
NPI:1689714404
Name:SOULE, GEORGE MELTON (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:MELTON
Last Name:SOULE
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 1:511 SW TENTH
Mailing Address - Street 2:SUITE 604
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2707
Mailing Address - Country:US
Mailing Address - Phone:503-234-6324
Mailing Address - Fax:503-234-7166
Practice Address - Street 1:511 SW TENTH
Practice Address - Street 2:SUITE 604
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2707
Practice Address - Country:US
Practice Address - Phone:503-234-6324
Practice Address - Fax:503-234-7166
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD119022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR059964Medicaid
A92721Medicare UPIN
OR059964Medicaid