Provider Demographics
NPI:1194729798
Name:COLIP, CHARLES L (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:COLIP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 SE MAIN ST
Mailing Address - Street 2:STE 203
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2442
Mailing Address - Country:US
Mailing Address - Phone:503-255-3054
Mailing Address - Fax:503-255-7651
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:STE 203
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2442
Practice Address - Country:US
Practice Address - Phone:503-255-3054
Practice Address - Fax:503-255-7651
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-10
Last Update Date:2007-07-09
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
OR11209174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR225284Medicaid
OR225284Medicaid
OR0000BHPBPMedicare ID - Type UnspecifiedMEDICARE