Healthcare Provider Details

I. General information

NPI: 1396776324
Provider Name (Legal Business Name): TRAVIS LOUIS MONCHAMP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 SW SIMPSON AVE SUITE 220
BEND OR
97702-3599
US

IV. Provider business mailing address

PO BOX 670
BEND OR
97709-0670
US

V. Phone/Fax

Practice location:
  • Phone: 541-317-5600
  • Fax: 541-317-5676
Mailing address:
  • Phone: 541-317-5600
  • Fax: 541-317-5676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License NumberMD26567
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD26567
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: