Provider Demographics
NPI:1154392454
Name:BOMENGEN, ROBERT W (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:BOMENGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 S J ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1680
Mailing Address - Country:US
Mailing Address - Phone:541-947-3366
Mailing Address - Fax:541-947-4404
Practice Address - Street 1:624 S J ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1680
Practice Address - Country:US
Practice Address - Phone:541-947-3366
Practice Address - Fax:541-947-4404
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR001073Medicaid
ORA52675Medicare UPIN
OR101628Medicare ID - Type Unspecified