Healthcare Provider Details

I. General information

NPI: 1952348096
Provider Name (Legal Business Name): ROBERT W HENRIQUES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NE 8TH ST
GRESHAM OR
97030-7317
US

IV. Provider business mailing address

619 NW 6TH AVE FL 5
PORTLAND OR
97209-3991
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-5558
  • Fax:
Mailing address:
  • Phone: 503-988-7468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD26122
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier096511
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier22959
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: