Provider Demographics
NPI:1376571364
Name:NORTHWEST DERMATOLOGY & LASER CLINIC PC
Entity Type:Organization
Organization Name:NORTHWEST DERMATOLOGY & LASER CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:TAVELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-295-2366
Mailing Address - Street 1:PO BOX 23200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97281-3200
Mailing Address - Country:US
Mailing Address - Phone:503-968-4620
Mailing Address - Fax:503-968-2779
Practice Address - Street 1:1130 NW 22ND AVE STE 330
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2970
Practice Address - Country:US
Practice Address - Phone:503-295-2366
Practice Address - Fax:503-295-3065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14681207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDD5356OtherRAILROAD MEDICARE
OR028071Medicaid
OR028071Medicaid
ORDD5356OtherRAILROAD MEDICARE