Provider Demographics
NPI:1194791640
Name:WATTENBURG, ERIC J (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:WATTENBURG
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:PO BOX 4858
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4858
Mailing Address - Country:US
Mailing Address - Phone:541-500-2500
Mailing Address - Fax:541-500-2700
Practice Address - Street 1:3818 SW 21ST ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756
Practice Address - Country:US
Practice Address - Phone:541-548-2899
Practice Address - Fax:541-504-3781
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78764207Q00000X
ORMD29323207Q00000X, 207P00000X
ID6761572207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00887743OtherMEDICARE RAILROAD
OR500608820Medicaid
CAOOA787640Medicaid
OR153744Medicare PIN
OR00887743OtherMEDICARE RAILROAD
CAOOA787640Medicare ID - Type Unspecified