Provider Demographics
NPI:1063691608
Name:RAYBURN, VERONICA MARY (DO)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:MARY
Last Name:RAYBURN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 SW MACADAM AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3519
Mailing Address - Country:US
Mailing Address - Phone:503-941-3077
Mailing Address - Fax:
Practice Address - Street 1:1425 BEAVERCREEK RD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045
Practice Address - Country:US
Practice Address - Phone:503-655-8471
Practice Address - Fax:503-655-8595
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO168755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500678098Medicaid