Healthcare Provider Details

I. General information

NPI: 1710970892
Provider Name (Legal Business Name): MARK HUNTINGTON WHITEFORD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 NE GLISAN ST SUITE 6N60
PORTLAND OR
97213-2933
US

IV. Provider business mailing address

541 NE 20TH AVE STE 225
PORTLAND OR
97232-2895
US

V. Phone/Fax

Practice location:
  • Phone: 503-281-0561
  • Fax: 503-416-7377
Mailing address:
  • Phone: 503-963-2801
  • Fax: 503-963-2825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD21976
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberMD21976
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: