Provider Demographics
NPI:1528155280
Name:NEWTON-KLUCEVEK, LISA MARIE (DO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:NEWTON-KLUCEVEK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 SW HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223
Mailing Address - Country:US
Mailing Address - Phone:503-293-0161
Mailing Address - Fax:503-221-4451
Practice Address - Street 1:9450 SW BARNES RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6642
Practice Address - Country:US
Practice Address - Phone:503-292-9560
Practice Address - Fax:503-292-9510
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO21207207Q00000X
OR0021207207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287850Medicaid
112421Medicare ID - Type Unspecified
H56715Medicare UPIN