Provider Demographics
NPI:1326117771
Name:HAUGHOM, JOHN LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LEE
Last Name:HAUGHOM
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 1:0841 SW GAINES ST UNIT 2204
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3105
Mailing Address - Country:US
Mailing Address - Phone:541-912-2573
Mailing Address - Fax:
Practice Address - Street 1:0841 SW GAINES ST UNIT 2204
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3105
Practice Address - Country:US
Practice Address - Phone:541-912-2573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12308207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR075598Medicare ID - Type Unspecified
ORC92833Medicare UPIN