Healthcare Provider Details

I. General information

NPI: 1194729798
Provider Name (Legal Business Name): CHARLES L COLIP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date: 03/16/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

10000 SE MAIN ST STE 203
PORTLAND OR
97216-2442
US

IV. Provider business mailing address

10000 SE MAIN ST STE 203
PORTLAND OR
97216-2442
US

V. Phone/Fax

Practice location:
  • Phone: 503-255-3054
  • Fax: 503-255-7651
Mailing address:
  • Phone: 503-255-3054
  • Fax: 503-255-7651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number11209
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: