Basic Information
| Provider Information | |||||||||
| NPI: | 1659342509 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUBLER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 N GRAHAM | ||||||||
| Address2: | SUITE #580 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035280704 | ||||||||
| FaxNumber: | 5035280708 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 N GRAHAM | ||||||||
| Address2: | SUITE #580 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035280704 | ||||||||
| FaxNumber: | 5035280708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 08/25/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | DO23244 | OR | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 20A4923 | CA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | OP00000951 | WA | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 287256 | 05 | OR | MEDICAID |