Healthcare Provider Details

I. General information

NPI: 1740368992
Provider Name (Legal Business Name): MELISSA ESHELMAN, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 NE GLISAN ST 3E
PORTLAND OR
97213-2933
US

IV. Provider business mailing address

3439 NE SANDY BLVD PMB 375
PORTLAND OR
97232-1959
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-7462
  • Fax: 503-215-7460
Mailing address:
  • Phone: 503-284-8841
  • Fax: 503-282-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD18604
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier149999
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: DR. MELISSA ESHELMAN
Title or Position: OWNER
Credential: MD
Phone: 503-215-7462