Provider Demographics
NPI:1851387146
Name:HERTLER, CRAIG KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:KEVIN
Last Name:HERTLER
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 1:2222 NW LOVEJOY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5104
Mailing Address - Country:US
Mailing Address - Phone:503-222-3638
Mailing Address - Fax:503-223-5139
Practice Address - Street 1:2222 NW LOVEJOY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5104
Practice Address - Country:US
Practice Address - Phone:503-222-3638
Practice Address - Fax:503-223-5139
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14722174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR012893Medicaid
OR012893Medicaid
ORE62339Medicare UPIN