Provider Demographics
NPI:1225356967
Name:BROTHERS, DINA ANNE (DO)
Entity Type:Individual
Prefix:MRS
First Name:DINA
Middle Name:ANNE
Last Name:BROTHERS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MRS
Other - First Name:DINA
Other - Middle Name:ANNE
Other - Last Name:KACICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1210 S FEDERAL ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3378
Mailing Address - Country:US
Mailing Address - Phone:630-337-6882
Mailing Address - Fax:
Practice Address - Street 1:1500 DIVISION ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1527
Practice Address - Country:US
Practice Address - Phone:503-650-6255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORDO167786207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDO167786OtherMEDICAL LICENSE
WAOP60499337OtherMEDICARE