Basic Information
| Provider Information | |||||||||
| NPI: | 1972504314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLOVER | ||||||||
| FirstName: | GEOFFERY | ||||||||
| MiddleName: | W.P. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948562 | ||||||||
| FaxNumber: | 5034185505 | ||||||||
| Practice Location | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948562 | ||||||||
| FaxNumber: | 5034185505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | DR.0041439 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | DR.0041439 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | MD204668 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207R00000X | MD204668 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 53455878 | 05 | CO | MEDICAID |