Provider Demographics
NPI:1134143464
Name:MECKLING, KENT FORREST (MD)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:FORREST
Last Name:MECKLING
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 1:7903 NW BLUE POINTE LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-9115
Mailing Address - Country:US
Mailing Address - Phone:503-292-6295
Mailing Address - Fax:
Practice Address - Street 1:8995 SW MILEY RD
Practice Address - Street 2:SUITE 204
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-5484
Practice Address - Country:US
Practice Address - Phone:503-292-6295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2016-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24567207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD5953RMedicaid
WA8381790Medicaid
ORP00467822OtherRR MEDICARE
OR274822Medicaid
OR274822Medicaid
AKMD5953RMedicaid
AKMD5953RMedicaid