Individual
DR. TYLER JUSTIN GLUCKMAN III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
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
(503) 215-6494
(503) 215-6644
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
D0058894
MD
207RC0000X
Cardiovascular Disease Physician
Primary
MD26695
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
240072
—
OR
01
—
P00348434
RR MEDICARE
OR
01
—
P00848623
RR MEDICARE
OR
Enumeration date
04/12/2006
Last updated
12/18/2012
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