Provider Demographics
NPI:1013919323
Name:GOBBLE, JOHN ELLIS (DRPH, RD, LD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ELLIS
Last Name:GOBBLE
Suffix:
Gender:M
Credentials:DRPH, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 SW 20TH CT
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-9662
Mailing Address - Country:US
Mailing Address - Phone:503-652-5070
Mailing Address - Fax:503-652-5080
Practice Address - Street 1:6542 SE LAKE RD STE 202C
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2244
Practice Address - Country:US
Practice Address - Phone:503-652-5070
Practice Address - Fax:800-957-1067
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
OR000543133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500641681Medicaid
OR500641681Medicaid