Basic Information
Provider Information | |||||||||
NPI: | 1881751071 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PICKERING | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: | DOUGLAS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7650 SW BEVELAND STREET | ||||||||
Address2: | SUITE 200 | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 97223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036013615 | ||||||||
FaxNumber: | 5038403299 | ||||||||
Practice Location | |||||||||
Address1: | 7431 NE EVERGREEN PKWY STE 100 | ||||||||
Address2: |   | ||||||||
City: | HILLSBORO | ||||||||
State: | OR | ||||||||
PostalCode: | 971245831 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5038403400 | ||||||||
FaxNumber: | 5038403409 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2007 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD175483 | OR | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 500696398 | 05 | OR |   | MEDICAID | 0475905 | 05 | IA |   | MEDICAID |