Healthcare Provider Details

I. General information

NPI: 1972559409
Provider Name (Legal Business Name): BENNETH ANN HUSTED D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 SW MACADAM AVE SUITE 200
PORTLAND OR
97239-6102
US

IV. Provider business mailing address

5100 SW MACADAM AVE SUITE 200
PORTLAND OR
97239-6102
US

V. Phone/Fax

Practice location:
  • Phone: 971-202-5500
  • Fax: 971-202-5555
Mailing address:
  • Phone: 971-202-5500
  • Fax: 971-202-5555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberDO12837
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: