Provider Demographics
NPI:1184742140
Name:SHERECK, EVAN (MD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:SHERECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD, MAIL CODE CDRC-P
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:503-494-0829
Mailing Address - Fax:503-494-0714
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD,
Practice Address - Street 2:MAIL CODE CDRC-P
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:503-494-0829
Practice Address - Fax:503-494-0714
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD152990208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500628915Medicaid
ORR156650Medicare PIN