Healthcare Provider Details

I. General information

NPI: 1538000294
Provider Name (Legal Business Name): ALEXANDER MOCKAITIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2026
Last Update Date: 04/04/2026
Certification Date: 04/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61690 PETTIGREW RD
BEND OR
97702-2422
US

IV. Provider business mailing address

61690 PETTIGREW RD
BEND OR
97702-2422
US

V. Phone/Fax

Practice location:
  • Phone: 541-617-0377
  • Fax: 833-776-0563
Mailing address:
  • Phone: 541-617-0377
  • Fax: 833-776-0563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number116718
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: