Healthcare Provider Details

I. General information

NPI: 1689091167
Provider Name (Legal Business Name): NICOLAS STADLBERGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9155 SW BARNES RD STE 420
PORTLAND OR
97225-6631
US

IV. Provider business mailing address

9155 SW BARNES RD STE 420
PORTLAND OR
97225-6631
US

V. Phone/Fax

Practice location:
  • Phone: 503-297-6334
  • Fax:
Mailing address:
  • Phone: 503-297-6334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD182794
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: