Healthcare Provider Details

I. General information

NPI: 1710110127
Provider Name (Legal Business Name): ROBERT L KALEZ MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 11/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24900 SE STARK ST 208
GRESHAM OR
97030-3355
US

IV. Provider business mailing address

24900 SE STARK ST 208
GRESHAM OR
97030-3355
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-3030
  • Fax: 503-666-3434
Mailing address:
  • Phone: 503-666-3030
  • Fax: 503-666-3434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number006014
License Number StateOR

VIII. Authorized Official

Name: ROBERT L KALEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 503-666-3030