Provider Demographics
NPI:1588606545
Name:LACEY, REBECCA (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:LACEY
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 1:9555 SW BARNES RD
Mailing Address - Street 2:STE 301
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6663
Mailing Address - Country:US
Mailing Address - Phone:503-297-3371
Mailing Address - Fax:503-297-7975
Practice Address - Street 1:9555 SW BARNES RD
Practice Address - Street 2:STE 301
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6663
Practice Address - Country:US
Practice Address - Phone:503-297-3371
Practice Address - Fax:503-297-7975
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD23772208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8371197Medicaid
OR275538Medicaid
OR275538Medicaid