Provider Demographics
NPI:1720176332
Name:DE LA BRUERE, BEVERLY ANN
Entity type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:ANN
Last Name:DE LA BRUERE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18151 SE HIGHWAY 212
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:OR
Mailing Address - Zip Code:97089-8764
Mailing Address - Country:US
Mailing Address - Phone:503-658-6022
Mailing Address - Fax:503-658-7818
Practice Address - Street 1:18151 SE HIGHWAY 212
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:OR
Practice Address - Zip Code:97089-8764
Practice Address - Country:US
Practice Address - Phone:503-658-6022
Practice Address - Fax:503-658-7818
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15031207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR110403Medicaid
ORC92493Medicare UPIN
OR110403Medicaid