Healthcare Provider Details

I. General information

NPI: 1316436785
Provider Name (Legal Business Name): NICHOLAS FOGELSON MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 07/05/2021
Certification Date: 07/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 SW 10TH AVE STE 907
PORTLAND OR
97205-2710
US

IV. Provider business mailing address

511 SW 10TH AVE STE 907
PORTLAND OR
97205-2710
US

V. Phone/Fax

Practice location:
  • Phone: 503-715-1377
  • Fax: 503-771-2717
Mailing address:
  • Phone: 503-715-1377
  • Fax: 503-771-2717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number173545
License Number StateOR

VIII. Authorized Official

Name: DR. NICHOLAS S FOGELSON
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 503-715-1377