Provider Demographics
NPI:1891760252
Name:KALEZ, ROBERT L (MD PC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:KALEZ
Suffix:
Gender:M
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24900 SE STARK #208
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030
Mailing Address - Country:US
Mailing Address - Phone:503-666-3030
Mailing Address - Fax:503-666-3434
Practice Address - Street 1:24900 SE STARK ST STE 208
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3382
Practice Address - Country:US
Practice Address - Phone:503-666-3030
Practice Address - Fax:503-666-3434
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD06014208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR103069Medicaid
C92997Medicare UPIN
ORR0000BHGHVMedicare PIN
ORR148476Medicare PIN