Provider Demographics
NPI:1144214743
Name:MANDIBERG, JOSEPH J (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:J
Last Name:MANDIBERG
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 1:5050 NE HOYT ST
Mailing Address - Street 2:SUITE 640
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2991
Mailing Address - Country:US
Mailing Address - Phone:503-231-1426
Mailing Address - Fax:503-231-0316
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:SUITE 640
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-231-1426
Practice Address - Fax:503-231-0316
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 11260207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR244731Medicaid
C91653Medicare UPIN
ORR0000BHPZMMedicare PIN