Provider Demographics
NPI:1578669487
Name:BURNINGHAM, ALAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:R
Last Name:BURNINGHAM
Suffix:
Gender:M
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 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:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:1003 PROVIDENCE DR
Practice Address - Street 2:STE 210
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7523
Practice Address - Country:US
Practice Address - Phone:503-537-9000
Practice Address - Fax:503-537-5955
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26532207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278331Medicaid
ORP01054230OtherRR MEDICARE (PH&S)-PMG
ORR145757Medicare PIN
LAI29724Medicare UPIN