Provider Demographics
NPI:1992954408
Name:MADDA, ROBERT (ND, LAC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:MADDA
Suffix:
Gender:M
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 NW 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2618
Mailing Address - Country:US
Mailing Address - Phone:503-347-4625
Mailing Address - Fax:503-208-7105
Practice Address - Street 1:1536 NW 23RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2618
Practice Address - Country:US
Practice Address - Phone:503-347-4625
Practice Address - Fax:503-208-7105
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR153733171100000X
OR1802175F00000X
CA10268171100000X
CANDF 184175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist