Provider Demographics
NPI:1033127410
Name:REDFERN, CRAIG CALVIN (DO)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:CALVIN
Last Name:REDFERN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 SE STARK ST STE 210
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3082
Mailing Address - Country:US
Mailing Address - Phone:503-235-3767
Mailing Address - Fax:503-236-9537
Practice Address - Street 1:2950 SE STARK ST STE 210
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3082
Practice Address - Country:US
Practice Address - Phone:503-235-3767
Practice Address - Fax:503-236-9537
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO14108207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR109189OtherGROUP MEDICARE NUMBER
OR048673Medicaid
OR048673Medicaid
ORD81483Medicare UPIN
OR109191Medicare ID - Type Unspecified