Basic Information
| Provider Information | |||||||||
| NPI: | 1407964968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KESTNER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 N GANTENBEIN AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972271623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034134647 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 501 N GRAHAM ST | ||||||||
| Address2: | SUITE 580 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972271654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035280704 | ||||||||
| FaxNumber: | 5035280708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD23365 | OR | X | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | MD23365 | OR | X | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | MD23365 | OR | X | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 287209 | 05 | OR | MEDICAID |