Provider Demographics
NPI:1568452738
Name:KORNGOLD, ETHAN CHAUNCEY (MD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:CHAUNCEY
Last Name:KORNGOLD
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9427 SW BARNES RD
Practice Address - Street 2:SUITE 498
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6652
Practice Address - Country:US
Practice Address - Phone:503-216-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217916207R00000X, 207RC0000X
ORMD29224207RC0000X, 207RI0011X
WAMD60107167207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00848656OtherRR MEDICARE
OR500609355Medicaid
ORR156592Medicare PIN
ORR154627Medicare PIN
WAG8899638Medicare PIN
ORR156985Medicare PIN
ORR154555Medicare PIN
OR500609355Medicaid