Healthcare Provider Details

I. General information

NPI: 1033111422
Provider Name (Legal Business Name): DEIDRE L BURTON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 NW 22ND AVE SUITE 320
PORTLAND OR
97210-2900
US

IV. Provider business mailing address

1130 NW 22ND AVE STE 320
PORTLAND OR
97210-2970
US

V. Phone/Fax

Practice location:
  • Phone: 503-295-2546
  • Fax: 503-790-1248
Mailing address:
  • Phone: 503-295-2546
  • Fax: 503-790-1248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD17996
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: