Provider Demographics
NPI:1396778916
Name:SELLARS, KEVIN R (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:SELLARS
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:1003 PROVIDENCE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7521
Practice Address - Country:US
Practice Address - Phone:503-537-5900
Practice Address - Fax:503-537-1820
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23180207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287499Medicaid
OR287499Medicaid
ORR130148Medicare PIN
H47790Medicare UPIN