Provider Demographics
NPI:1033158084
Name:CAVERZAGIE, KELLY JOHN (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JOHN
Last Name:CAVERZAGIE
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 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-1164
Mailing Address - Fax:503-494-5502
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-1164
Practice Address - Fax:503-494-5502
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD222456207R00000X, 208M00000X
NE22784207R00000X
PAMD426638207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101537515Medicaid
PA098821Medicare ID - Type Unspecified
PA101537515Medicaid