Provider Demographics
NPI:1184783094
Name:PODETT, PAUL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:PODETT
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 1:24900 SE STARK ST STE 205
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3382
Mailing Address - Country:US
Mailing Address - Phone:503-665-1010
Mailing Address - Fax:503-665-1023
Practice Address - Street 1:24900 SE STARK ST STE 205
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:503-665-1010
Practice Address - Fax:503-665-1023
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18120207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR120977Medicaid
ORR120129Medicare ID - Type Unspecified
ORR120127Medicare ID - Type Unspecified
OR120977Medicaid