Provider Demographics
NPI:1972548469
Name:RELLER, MARK D (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:RELLER
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Gender:M
Credentials:MD
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Mailing Address - Street 1:707 SW GAINES ST
Mailing Address - Street 2:CDRC-P
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2901
Mailing Address - Country:US
Mailing Address - Phone:503-494-2192
Mailing Address - Fax:503-494-2824
Practice Address - Street 1:707 SW GAINES ST
Practice Address - Street 2:CDRC-P
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2901
Practice Address - Country:US
Practice Address - Phone:503-494-2192
Practice Address - Fax:503-494-2824
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2011-11-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD13950208000000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC93597Medicare UPIN