Provider Demographics
NPI:1104898956
Name:BELLER, KLARISSA N (MD)
Entity type:Individual
Prefix:DR
First Name:KLARISSA
Middle Name:N
Last Name:BELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KLARISSA
Other - Middle Name:K
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 24410
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-0451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 HILYARD ST STE 520A
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8122
Practice Address - Country:US
Practice Address - Phone:541-687-6041
Practice Address - Fax:541-687-6009
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286635Medicaid
ORR113600Medicare PIN
H64491Medicare UPIN
ORRR PTAN 110244016Medicare PIN