Healthcare Provider Details

I. General information

NPI: 1912129297
Provider Name (Legal Business Name): LAWRENCE FRANKLIN MACKLES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8835 SW CANYON LANE #240
PORTLAND OR
97225
US

IV. Provider business mailing address

8835 SW CANYON LANE #240
PORTLAND OR
97225
US

V. Phone/Fax

Practice location:
  • Phone: 503-292-5439
  • Fax:
Mailing address:
  • Phone: 503-292-5439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number14141
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: