Provider Demographics
NPI:1881677474
Name:STULL, CAROL G (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:G
Last Name:STULL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7650 SW BEVELAND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8692
Mailing Address - Country:US
Mailing Address - Phone:503-292-3577
Mailing Address - Fax:503-292-3947
Practice Address - Street 1:9555 SW BARNES RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6663
Practice Address - Country:US
Practice Address - Phone:503-292-3577
Practice Address - Fax:503-292-3947
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD 21384207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151223Medicaid
ORR106586OtherMEDICARE PTAN
OR151223Medicaid