Provider Demographics
NPI:1699731455
Name:WARDA, ROBERT F (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:F
Last Name:WARDA
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 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10201 SE MAIN ST
Practice Address - Street 2:SUITE 10
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2937
Practice Address - Country:US
Practice Address - Phone:503-255-2186
Practice Address - Fax:503-255-2194
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287158Medicaid
OR110456Medicare ID - Type Unspecified
OR287158Medicaid