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General NPI Number Information
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NPI Number | 1639310774
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Entity Type | Individual
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Provider Name | KEITH LELAND IRONSIDE JR. M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/19/2009
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Last Update Date | 09/17/2013
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Provider Practice Location Address
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Address Line | 6464 SW BORLAND RD SUITE B2
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City | TUALATIN
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State | OR
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Zip | 97062-8876
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Country | US
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Telephone | 503-612-9676
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Fax | 866-360-3540
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Provider Business Mailing Address
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Address Line | 6464 SW BORLAND RD SUITE B2
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City | TUALATIN
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State | OR
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Zip | 97062-8876
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Country | US
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Telephone | 503-612-9676
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Fax | 866-360-3540
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MD09750
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 173F00000X
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Taxonomy Name | Sleep Specialist (PhD)
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License Number | MD09750
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License Number State | OR
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