Healthcare Provider Details

I. General information

NPI: 1003995945
Provider Name (Legal Business Name): MELISSA BETH BUBOLTZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD UHN 80
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

5156 SW MULTNOMAH BLVD UNIT K
PORTLAND OR
97219-3372
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-8311
  • Fax:
Mailing address:
  • Phone: 503-977-7903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD26388
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: