Provider Demographics
NPI:1033230800
Name:LANFORD, JEREMIAH W (MD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:W
Last Name:LANFORD
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:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-0670
Mailing Address - Country:US
Mailing Address - Phone:541-706-5770
Mailing Address - Fax:541-429-6669
Practice Address - Street 1:2450 NE MARY ROSE PL STE 210
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7133
Practice Address - Country:US
Practice Address - Phone:541-706-5770
Practice Address - Fax:541-429-6669
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM58082084N0400X, 2084N0600X
ORMD1857692084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD185769OtherSTATE LICENSE