Provider Demographics
NPI:1033111422
Name:BURTON, DEIDRE L (MD)
Entity type:Individual
Prefix:
First Name:DEIDRE
Middle Name:L
Last Name:BURTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 NW 22ND AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2970
Mailing Address - Country:US
Mailing Address - Phone:503-295-2546
Mailing Address - Fax:503-790-1248
Practice Address - Street 1:1130 NW 22ND AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2900
Practice Address - Country:US
Practice Address - Phone:503-295-2546
Practice Address - Fax:503-790-1248
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17996208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR056429Medicaid
OR056429Medicaid
F56646Medicare UPIN