Provider Demographics
NPI:1689797169
Name:THE WALDORF CENTER FOR PLASTIC SURGERY
Entity Type:Organization
Organization Name:THE WALDORF CENTER FOR PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALDORF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-646-0101
Mailing Address - Street 1:12400 NW CORNELL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5689
Mailing Address - Country:US
Mailing Address - Phone:503-646-0101
Mailing Address - Fax:503-350-1420
Practice Address - Street 1:12400 NW CORNELL RD STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5689
Practice Address - Country:US
Practice Address - Phone:503-646-0101
Practice Address - Fax:503-350-1420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR060207Medicaid
ORR104664Medicare ID - Type UnspecifiedFACILITY