Provider Demographics
NPI:1316150022
Name:BASHAM, CHANDRA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:CHANDRA
Middle Name:MARIE
Last Name:BASHAM
Suffix:
Gender:F
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 22061
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2061
Mailing Address - Country:US
Mailing Address - Phone:503-659-1978
Mailing Address - Fax:
Practice Address - Street 1:10535 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4077
Practice Address - Country:US
Practice Address - Phone:503-273-5142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 27394207Q00000X
ORMD27394390200000X
CAA97048390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program