Provider Demographics
NPI:1639318181
Name:FOGEL, GERALD I (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:I
Last Name:FOGEL
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 1:2455 NW MARSHALL ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-224-7395
Mailing Address - Fax:503-223-5802
Practice Address - Street 1:2455 NW MARSHALL ST
Practice Address - Street 2:SUITE 5
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2949
Practice Address - Country:US
Practice Address - Phone:503-224-7395
Practice Address - Fax:503-223-5802
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19867102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst