Healthcare Provider Details

I. General information

NPI: 1356566525
Provider Name (Legal Business Name): KATE BENEDICT DEISSEROTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 SW VERMONT ST APT 305
PORTLAND OR
97223-7568
US

IV. Provider business mailing address

7000 SW VERMONT ST APT 305
PORTLAND OR
97223-7568
US

V. Phone/Fax

Practice location:
  • Phone: 503-866-7299
  • Fax:
Mailing address:
  • Phone: 503-866-7299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: