Healthcare Provider Details

I. General information

NPI: 1649215336
Provider Name (Legal Business Name): BRADFORD BENTON LORBER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 SW BEAVERTON HILLSDALE HWY SUITE 205
BEAVERTON OR
97005-3315
US

IV. Provider business mailing address

9400 SW BEAVERTON HILLSDALE HWY SUITE 205
BEAVERTON OR
97005-3315
US

V. Phone/Fax

Practice location:
  • Phone: 503-684-7246
  • Fax: 503-624-0724
Mailing address:
  • Phone: 503-684-7246
  • Fax: 503-624-0724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD22166
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: