Healthcare Provider Details

I. General information

NPI: 1770788077
Provider Name (Legal Business Name): CARL HEISEL R.PH, BCPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 N GANTENBEIN AVE
PORTLAND OR
97227-1623
US

IV. Provider business mailing address

5810 SW LURADEL CT
PORTLAND OR
97219-5780
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-4290
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number6146
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: