Provider Demographics
NPI:1114050754
Name:DE FONTES, DEANE C (MD)
Entity Type:Individual
Prefix:
First Name:DEANE
Middle Name:C
Last Name:DE FONTES
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 1:426 SW STARK ST
Mailing Address - Street 2:8TH FLOOR
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-2347
Mailing Address - Country:US
Mailing Address - Phone:503-988-3674
Mailing Address - Fax:503-988-3142
Practice Address - Street 1:426 SW STARK ST
Practice Address - Street 2:8TH FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-2347
Practice Address - Country:US
Practice Address - Phone:503-988-3674
Practice Address - Fax:503-988-3142
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMC24712207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022959Medicaid
OR118512Medicare PIN
OR022959Medicaid