Provider Demographics
NPI:1437103223
Name:GLASS, ANDREW D (DO)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:D
Last Name:GLASS
Suffix:
Gender:M
Credentials:DO
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 1:16770 SW EDY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9678
Practice Address - Country:US
Practice Address - Phone:503-215-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001849207Q00000X
ORDO21335207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00946511OtherRR MEDICARE
WA8463606Medicaid
OR288469Medicaid
ORR152868Medicare PIN
ORR152871Medicare PIN
H13994Medicare UPIN
OR288469Medicaid
ORR152867Medicare PIN
WA8463606Medicaid
AB36941Medicare ID - Type Unspecified
ORR152869Medicare PIN