Healthcare Provider Details

I. General information

NPI: 1194791640
Provider Name (Legal Business Name): ERIC J WATTENBURG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3818 SW 21ST ST
REDMOND OR
97756
US

IV. Provider business mailing address

PO BOX 4858
PORTLAND OR
97208-4858
US

V. Phone/Fax

Practice location:
  • Phone: 541-548-2899
  • Fax: 541-504-3781
Mailing address:
  • Phone: 541-500-2500
  • Fax: 541-500-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA78764
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD29323
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD29323
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6761572
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: