Provider Demographics
NPI:1932124369
Name:SHATSKY, MARK L (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:SHATSKY
Suffix:
Gender:M
Credentials:DO
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 1:18040 SW LOWER BOONES FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7258
Practice Address - Country:US
Practice Address - Phone:503-216-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25748207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00252349OtherRR MEDICARE
OR269756Medicaid
ORR156933Medicare PIN
ORR141814Medicare PIN
ORR136216Medicare PIN
OR269756Medicaid
ORR144553Medicare PIN
ORR156934Medicare PIN
ORR156932Medicare PIN