Provider Demographics
NPI:1790749422
Name:GLUCKMAN, TYLER JUSTIN III (MD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:JUSTIN
Last Name:GLUCKMAN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TY
Other - Middle Name:JUSTIN
Other - Last Name:GLUCKMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:9427 SW BARNES RD
Practice Address - Street 2:SUITE 498
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6652
Practice Address - Country:US
Practice Address - Phone:503-216-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0058894207RC0000X
ORMD26695207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240072Medicaid
ORP00848623OtherRR MEDICARE
ORP00348434OtherRR MEDICARE
OR240072Medicaid
ORR156591Medicare PIN
ORR159875Medicare PIN
ORR154644Medicare PIN
ORR156015Medicare PIN
ORR154588Medicare PIN
ORH20606Medicare UPIN
ORR134784Medicare PIN