Provider Demographics
NPI:1881633980
Name:KINGMAN, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KINGMAN
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 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 1:18610 NW CORNELL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-9204
Practice Address - Country:US
Practice Address - Phone:503-216-9300
Practice Address - Fax:503-216-9363
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17111207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00351748OtherRR MEDICARE
OR169784Medicaid
ORD43205Medicare UPIN
ORR146009Medicare PIN
ORP00351748OtherRR MEDICARE
ORR133923Medicare PIN
ORR151318Medicare PIN
ORR151319Medicare PIN
OR169784Medicaid
ORR158615Medicare PIN
ORR147484Medicare PIN