Provider Demographics
NPI:1326022187
Name:HATFIELD, MARK TRAVIS (DPT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:TRAVIS
Last Name:HATFIELD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 SW BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-3413
Mailing Address - Country:US
Mailing Address - Phone:503-222-1955
Mailing Address - Fax:503-222-1485
Practice Address - Street 1:1420 SW BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-3413
Practice Address - Country:US
Practice Address - Phone:503-222-1955
Practice Address - Fax:503-222-1485
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4986225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR140277Medicare PIN