Healthcare Provider Details

I. General information

NPI: 1992618318
Provider Name (Legal Business Name): BRYAN R MENDESDACOSTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 SE DIVISION ST STE 100
PORTLAND OR
97206-1628
US

IV. Provider business mailing address

847 NE 19TH AVE STE 100
PORTLAND OR
97232-2684
US

V. Phone/Fax

Practice location:
  • Phone: 503-238-0705
  • Fax: 503-236-7166
Mailing address:
  • Phone: 503-674-7777
  • Fax: 503-235-5049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number2533680
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: