Provider Demographics
NPI:1043254378
Name:KALE, KEITH W (DO)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:W
Last Name:KALE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10748 NE HALSEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3961
Mailing Address - Country:US
Mailing Address - Phone:503-255-9400
Mailing Address - Fax:
Practice Address - Street 1:10748 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3961
Practice Address - Country:US
Practice Address - Phone:503-255-9400
Practice Address - Fax:503-255-9402
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO17457207Q00000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR036207Medicaid
ORF00103Medicare UPIN
OR036207Medicaid