Provider Demographics
NPI:1851824098
Name:HACKETT, BENJAMIN DAVIS (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DAVIS
Last Name:HACKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:9427 SW BARNES RD STE 296
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6667
Practice Address - Country:US
Practice Address - Phone:503-297-3778
Practice Address - Fax:503-297-7853
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-10607207RP1001X
ORMD220746207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2291816Medicaid
OR500841944Medicaid