Provider Demographics
NPI:1013971837
Name:MELVIN, KENNETH PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PAUL
Last Name:MELVIN
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 1:6975 SW SANDBURG ST
Mailing Address - Street 2:SUITE 190
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8073
Mailing Address - Country:US
Mailing Address - Phone:503-639-0600
Mailing Address - Fax:
Practice Address - Street 1:4035 MERCANTILE DR
Practice Address - Street 2:SUITE 112
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2546
Practice Address - Country:US
Practice Address - Phone:503-203-1177
Practice Address - Fax:503-203-1178
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 24232207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269812Medicaid
ORMD24232OtherMEDICAL LICENCE NUMBER
ORMD24232OtherMEDICAL LICENCE NUMBER