Healthcare Provider Details

I. General information

NPI: 1669655213
Provider Name (Legal Business Name): ROBERT H MCGLYNN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 02/20/2021
Certification Date: 02/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10819 SE STARK ST
PORTLAND OR
97216-3161
US

IV. Provider business mailing address

PO BOX 22009
PORTLAND OR
97269-2009
US

V. Phone/Fax

Practice location:
  • Phone: 503-255-2291
  • Fax: 503-252-1797
Mailing address:
  • Phone: 503-558-7372
  • Fax: 503-344-5140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD173218
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberMD173218
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: