Provider Demographics
NPI:1104844661
Name:CRAFT, RICHARD WAYNE SR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WAYNE
Last Name:CRAFT
Suffix:SR
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 1:24900 SE STARK ST
Mailing Address - Street 2:STE 202
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030
Mailing Address - Country:US
Mailing Address - Phone:503-465-8887
Mailing Address - Fax:503-465-8808
Practice Address - Street 1:24900 SE STARK ST STE 202
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3382
Practice Address - Country:US
Practice Address - Phone:503-465-8887
Practice Address - Fax:503-465-8808
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16231207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR044453Medicaid
E79228Medicare UPIN
0000BJBJCMedicare ID - Type Unspecified