Healthcare Provider Details

I. General information

NPI: 1376541995
Provider Name (Legal Business Name): RICHARD BOYD PHIPPS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 08/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 NE BURNSIDE RD SUITE 704
GRESHAM OR
97030-6722
US

IV. Provider business mailing address

1217 NE BURNSIDE RD SUITE 704
GRESHAM OR
97030-6722
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-2577
  • Fax: 503-492-4546
Mailing address:
  • Phone: 503-661-2577
  • Fax: 503-492-4546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD11864
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD11864
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: