Provider Demographics
NPI:1346466323
Name:ROBERTS, BRENDA DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:DIANE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:DIANE
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16180 SE SUNNYSIDE RD
Practice Address - Street 2:STE 102
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97015-6301
Practice Address - Country:US
Practice Address - Phone:503-582-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 21507207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01369929OtherRR MEDICARE (PH&S)
OR276859Medicaid
ORR174895Medicare PIN
ORP01369929OtherRR MEDICARE (PH&S)
ORR175070Medicare PIN
ORR177789Medicare PIN