Provider Demographics
NPI:1114900644
Name:VERDIECK DEVLAEMINCK, ALEXANDRA (MD)
Entity Type:Individual
Prefix:MS
First Name:ALEXANDRA
Middle Name:
Last Name:VERDIECK DEVLAEMINCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:ALEXANDRA
Other - Middle Name:
Other - Last Name:VERDIECK-LAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3303 SW BOND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4501
Mailing Address - Country:US
Mailing Address - Phone:503-494-8573
Mailing Address - Fax:503-494-3457
Practice Address - Street 1:3303 SW BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4501
Practice Address - Country:US
Practice Address - Phone:503-494-8573
Practice Address - Fax:503-494-3457
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20728207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR080156436OtherRR MEDICARE
OR134090Medicaid
OR134090Medicaid
OR080156436OtherRR MEDICARE