Provider Demographics
NPI:1194770370
Name:ROOT, DANIEL BRYAN (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:BRYAN
Last Name:ROOT
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 1:2228 NW PETTYGROVE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2608
Mailing Address - Country:US
Mailing Address - Phone:503-288-5201
Mailing Address - Fax:503-972-7234
Practice Address - Street 1:2228 NW PETTYGROVE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2608
Practice Address - Country:US
Practice Address - Phone:503-288-5201
Practice Address - Fax:503-972-7234
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17937207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR046016Medicaid
OR046016Medicaid
OR104329Medicare ID - Type Unspecified