Provider Demographics
NPI:1962407890
Name:TRELSTAD, DONALD A (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:A
Last Name:TRELSTAD
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 1:1040 NW 22ND AVE
Mailing Address - Street 2:STE 660
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3083
Mailing Address - Country:US
Mailing Address - Phone:503-692-0405
Mailing Address - Fax:503-692-7978
Practice Address - Street 1:19260 SW 65TH AVE
Practice Address - Street 2:STE 420
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-5712
Practice Address - Country:US
Practice Address - Phone:503-692-0405
Practice Address - Fax:503-692-7978
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09256174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR019729Medicaid
OR00WCHVVCMedicare ID - Type Unspecified
ORC93964Medicare UPIN