Healthcare Provider Details

I. General information

NPI: 1942356605
Provider Name (Legal Business Name): KELVIN D MACDONALD M.D., R.R.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 SW GAINES ST CDRCP
PORTLAND OR
97239-2901
US

IV. Provider business mailing address

707 SW GAINES ST CDRCP
PORTLAND OR
97239-2901
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-8023
  • Fax: 503-494-8898
Mailing address:
  • Phone: 503-494-8023
  • Fax: 503-494-8898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberD0062047
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberMD161212
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: