Provider Demographics
NPI:1538291547
Name:EVETTS, BRENT K (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:K
Last Name:EVETTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19875 SW 65TH AVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8353
Mailing Address - Country:US
Mailing Address - Phone:503-691-1743
Mailing Address - Fax:503-691-0983
Practice Address - Street 1:19875 SW 65TH AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8353
Practice Address - Country:US
Practice Address - Phone:503-691-1743
Practice Address - Fax:503-691-0983
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20653174400000X, 208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150330Medicaid
OR931272862OtherFEDERAL TAX ID NUMBER
ORR105002Medicare PIN
OR931272862OtherFEDERAL TAX ID NUMBER