Individual
ETHAN CHAUNCEY KORNGOLD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
9427 SW BARNES RD, SUITE 498, PORTLAND, OR 97225-6652
(503) 216-0900
Mailing address
PO BOX 3158, PORTLAND, OR 97208-3158
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
217916
MA
207RC0000X
Cardiovascular Disease Physician
217916
MA
207RC0000X
Cardiovascular Disease Physician
MD29224
OR
207RI0011X
Interventional Cardiology Physician
Primary
MD29224
OR
207RI0011X
Interventional Cardiology Physician
MD60107167
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500609355
—
OR
01
—
P00848656
RR MEDICARE
OR
Enumeration date
10/27/2005
Last updated
03/19/2021
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