Provider Demographics
NPI:1033100714
Name:PATAROQUE, BENITO G (MD)
Entity Type:Individual
Prefix:DR
First Name:BENITO
Middle Name:G
Last Name:PATAROQUE
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 1:6485 SW BORLAND RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9762
Mailing Address - Country:US
Mailing Address - Phone:503-692-3647
Mailing Address - Fax:503-691-1670
Practice Address - Street 1:6485 SW BORLAND RD
Practice Address - Street 2:SUITE D
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9762
Practice Address - Country:US
Practice Address - Phone:503-692-3647
Practice Address - Fax:503-691-1670
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23386207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR181643Medicaid
ORG15955Medicare UPIN
ORR111538Medicare PIN