Provider Demographics
NPI:1336296243
Name:DESITTER, LINDA L (MD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:L
Last Name:DESITTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:LAW
Other - Last Name:DESITTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6410 NE HALSEY ST
Practice Address - Street 2:SUITE 600
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-4742
Practice Address - Country:US
Practice Address - Phone:503-215-2669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15061207Q00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01215617OtherRR MEDIARE - PHS
ORR159121Medicare PIN
ORA53110Medicare UPIN