Provider Demographics
NPI:1346218831
Name:EUBANKS, BRIAN DAVID (PT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DAVID
Last Name:EUBANKS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S STATE ST
Mailing Address - Street 2:SUITE 200G
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3900
Mailing Address - Country:US
Mailing Address - Phone:503-860-6242
Mailing Address - Fax:
Practice Address - Street 1:10466 SE MAIN ST
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7509
Practice Address - Country:US
Practice Address - Phone:503-353-9976
Practice Address - Fax:503-353-9777
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4138225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR232013Medicaid
OR232013Medicaid