Provider Demographics
NPI:1720068596
Name:INGRAHAM, PAUL R (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:R
Last Name:INGRAHAM
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 3390
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3390
Mailing Address - Country:US
Mailing Address - Phone:503-215-6019
Mailing Address - Fax:
Practice Address - Street 1:1108 JUNE ST
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1513
Practice Address - Country:US
Practice Address - Phone:541-387-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17747207R00000X
ORMD216510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ276718Medicaid
AZC99684Medicare UPIN
AZ25215Medicare ID - Type Unspecified