Provider Demographics
NPI:1801463831
Name:GUMTANG, MARK KEVIN (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:MARK KEVIN
Middle Name:
Last Name:GUMTANG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7067 SE BLANTON ST APT 5304
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-2701
Mailing Address - Country:US
Mailing Address - Phone:808-282-1195
Mailing Address - Fax:
Practice Address - Street 1:2512 SE 109TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1215
Practice Address - Country:US
Practice Address - Phone:503-388-3755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64108225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist