Provider Demographics
NPI:1770599185
Name:ENSROTH, KENNETH ALAN (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALAN
Last Name:ENSROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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:503-722-3700
Mailing Address - Fax:503-722-3750
Practice Address - Street 1:1500 DIVISION ST
Practice Address - Street 2:CHILD CLINIC
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1527
Practice Address - Country:US
Practice Address - Phone:503-722-3700
Practice Address - Fax:503-722-3750
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD229532084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287772Medicaid
OR500656755Medicaid
ORR114409Medicare PIN
ORE55771Medicare UPIN
OR287772Medicaid