Provider Demographics
NPI:1790854610
Name:MCCARTHY, MARY K (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 NW NORTHRUP
Mailing Address - Street 2:#201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2955
Mailing Address - Country:US
Mailing Address - Phone:503-274-5417
Mailing Address - Fax:503-279-8828
Practice Address - Street 1:2311 NW NORTHRUP
Practice Address - Street 2:#201
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2955
Practice Address - Country:US
Practice Address - Phone:503-274-5417
Practice Address - Fax:503-279-8828
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD137072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR136580Medicaid
080942000OtherFEGENDA BLUE CROSS
OR136580Medicaid
0000BHWVWMedicare ID - Type Unspecified