Provider Demographics
NPI:1750587945
Name:GABBERT, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:GABBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE STE 300
Mailing Address - Street 2:SUITE 2005
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2686
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 NE 99TH AVE STE 301
Practice Address - Street 2:SUITE 2005
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9442
Practice Address - Country:US
Practice Address - Phone:503-963-2707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD189045207RG0100X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2104125Medicaid
OR500748065Medicaid