Provider Demographics
NPI:1396765236
Name:PATHIAL, KISHORE GOPINATHAN (MD)
Entity type:Individual
Prefix:
First Name:KISHORE
Middle Name:GOPINATHAN
Last Name:PATHIAL
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 1:2397 NE CUMULUS AVE
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6257
Mailing Address - Country:US
Mailing Address - Phone:503-472-5163
Mailing Address - Fax:
Practice Address - Street 1:2397 NE CUMULUS AVE
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6257
Practice Address - Country:US
Practice Address - Phone:503-472-5163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR695279-1207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR055884Medicaid
OR055884Medicaid
OR119483Medicare ID - Type Unspecified