Healthcare Provider Details

I. General information

NPI: 1962612283
Provider Name (Legal Business Name): CHARLES KRISTIAN ENESTVEDT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD DEPARTMENT OF SURGICAL ONCOLOGY, L619
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD L619
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-8592
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberMD151458
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberMD151458
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: