Healthcare Provider Details

I. General information

NPI: 1114344058
Provider Name (Legal Business Name): THIEBAUT THOMAS HERZOG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 11/03/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NE NEFF RD
BEND OR
97701-6015
US

IV. Provider business mailing address

2801 N GANTENBEIN AVE
PORTLAND OR
97227-1623
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-4321
  • Fax:
Mailing address:
  • Phone: 503-276-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1114344058
License Number StateWA

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: