Provider Demographics
NPI:1003805417
Name:BURGESS, ELISA A (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:A
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3439 NE SANDY BLVD
Mailing Address - Street 2:PMB 375
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1959
Mailing Address - Country:US
Mailing Address - Phone:503-284-8841
Mailing Address - Fax:503-282-3302
Practice Address - Street 1:16865 BOONES FERRY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5280
Practice Address - Country:US
Practice Address - Phone:503-699-6464
Practice Address - Fax:503-699-6939
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2011-11-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD18936208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H44122Medicare UPIN
ORR0000110016Medicare ID - Type Unspecified