Provider Demographics
NPI:1912147562
Name:GOLDBY, MARK FREDERIC (LAC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:FREDERIC
Last Name:GOLDBY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 EAST BURNSIDE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:503-232-3857
Mailing Address - Fax:
Practice Address - Street 1:1011 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1328
Practice Address - Country:US
Practice Address - Phone:503-232-3857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00297171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist