Healthcare Provider Details

I. General information

NPI: 1801095773
Provider Name (Legal Business Name): BENJAMIN R LAFFERTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 PLEASANT VIEW WAY NW STE 300
ALBANY OR
97321-1789
US

IV. Provider business mailing address

PO BOX 1189
CORVALLIS OR
97339-1189
US

V. Phone/Fax

Practice location:
  • Phone: 541-812-3323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number22405
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD177090
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500709165
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier3810015793
Identifier TypeMEDICAID
Identifier StateWV
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: