Provider Demographics
NPI:1164624722
Name:BLUMBERG, JACK BURTON (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:BURTON
Last Name:BLUMBERG
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 1:2521 NW UPSHUR ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2549
Mailing Address - Country:US
Mailing Address - Phone:503-223-0394
Mailing Address - Fax:503-241-2757
Practice Address - Street 1:2521 NW UPSHUR ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2549
Practice Address - Country:US
Practice Address - Phone:503-223-0394
Practice Address - Fax:503-241-2757
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5643208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery