Provider Demographics
NPI:1225176324
Name:BRADDOCK, JOHN RODGERS (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RODGERS
Last Name:BRADDOCK
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 1:4000 KRUSE WAY PL
Mailing Address - Street 2:BUILDING 2, SUITE 160
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5545
Mailing Address - Country:US
Mailing Address - Phone:503-635-1960
Mailing Address - Fax:503-635-8354
Practice Address - Street 1:4000 KRUSE WAY PL
Practice Address - Street 2:BUILDING 2, SUITE 160
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5545
Practice Address - Country:US
Practice Address - Phone:503-635-1960
Practice Address - Fax:503-635-8354
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09593207P00000X, 2083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC92264Medicare UPIN