Healthcare Provider Details

I. General information

NPI: 1215431960
Provider Name (Legal Business Name): MARISSA BONUS LUCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA LUCK BONUS MD

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 SW 15TH AVE
PORTLAND OR
97205-1907
US

IV. Provider business mailing address

808 SW 15TH AVE
PORTLAND OR
97205-1907
US

V. Phone/Fax

Practice location:
  • Phone: 503-274-4774
  • Fax:
Mailing address:
  • Phone: 503-274-4994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD209009
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberMD209009
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: