Provider Demographics
NPI:1902871932
Name:CALLAHAN, KERRY BEN (MD)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:BEN
Last Name:CALLAHAN
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 1:800 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1902
Mailing Address - Country:US
Mailing Address - Phone:503-221-0161
Mailing Address - Fax:
Practice Address - Street 1:541 NE 20TH AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-233-6940
Practice Address - Fax:503-236-2676
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16630207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8138299Medicaid
WA49534OtherWA DEPT. L&I
OR043484Medicaid
OR043484Medicaid
WA8138299Medicaid
OROOWCJQGGMedicare ID - Type Unspecified