Healthcare Provider Details

I. General information

NPI: 1851387146
Provider Name (Legal Business Name): CRAIG KEVIN HERTLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 NW LOVEJOY ST
PORTLAND OR
97210-5104
US

IV. Provider business mailing address

2222 NW LOVEJOY ST
PORTLAND OR
97210-5104
US

V. Phone/Fax

Practice location:
  • Phone: 503-222-3638
  • Fax: 503-223-5139
Mailing address:
  • Phone: 503-222-3638
  • Fax: 503-223-5139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD14722
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: