Provider Demographics
NPI:1255391033
Name:REPLOGLE, MARILYN LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:LOUISE
Last Name:REPLOGLE
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 1:4529 SW BRUGGER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5246
Mailing Address - Country:US
Mailing Address - Phone:503-452-8542
Mailing Address - Fax:
Practice Address - Street 1:1015 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3025
Practice Address - Country:US
Practice Address - Phone:503-413-3051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23972207R00000X, 208M00000X
UT4840589-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286568Medicaid
OR286568Medicaid
OR115353Medicare ID - Type Unspecified