Provider Demographics
NPI:1760483754
Name:LECLERC, KENNETH M (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:LECLERC
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 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:19250 SW 65TH AVE, SUITE 265
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062
Practice Address - Country:US
Practice Address - Phone:503-413-7162
Practice Address - Fax:503-692-2101
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4038207RC0000X
ORMD172293207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500685619Medicaid
OR500685619Medicaid