Healthcare Provider Details

I. General information

NPI: 1225050834
Provider Name (Legal Business Name): JIMMY DEE HUEBERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7654 SW MOHAWK ST BLDG K
TUALATIN OR
97062-8119
US

IV. Provider business mailing address

7654 SW MOHAWK ST BLDG K
TUALATIN OR
97062-8119
US

V. Phone/Fax

Practice location:
  • Phone: 503-691-2000
  • Fax: 503-961-2001
Mailing address:
  • Phone: 503-691-2000
  • Fax: 503-961-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberMD23362
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: