Provider Demographics
NPI:1972625044
Name:COLER, FRED KENT (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:KENT
Last Name:COLER
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 1:921 SW WASHINGTON
Mailing Address - Street 2:SUITE 812
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2826
Mailing Address - Country:US
Mailing Address - Phone:503-279-9004
Mailing Address - Fax:503-916-8181
Practice Address - Street 1:921 SW WASHINGTON
Practice Address - Street 2:SUITE 812
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2826
Practice Address - Country:US
Practice Address - Phone:503-279-9004
Practice Address - Fax:503-916-8181
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR198962084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150050Medicaid
G49220Medicare UPIN
100057Medicare ID - Type Unspecified