Provider Demographics
NPI:1407960388
Name:DEFREEST, MELISSA S (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:S
Last Name:DEFREEST
Suffix:
Gender:F
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:PO BOX 4078
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4078
Mailing Address - Country:US
Mailing Address - Phone:888-633-0086
Mailing Address - Fax:
Practice Address - Street 1:1255 HILYARD ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3718
Practice Address - Country:US
Practice Address - Phone:503-686-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD41141207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
215628OtherWASHINGTON L&I
WA8465049Medicaid
OR278470Medicaid
I62501OtherLIPA
I62501OtherPROVIDENCE
CAXPY206324Medicaid
I62501OtherGROUP HEALTH
CD2802Medicare PIN
I62501OtherPROVIDENCE
CAXPY206324Medicaid
OR278470Medicaid
P00347172Medicare PIN