Provider Demographics
NPI:1609950849
Name:BONG, CLIFFTON TH (MD)
Entity Type:Individual
Prefix:DR
First Name:CLIFFTON
Middle Name:TH
Last Name:BONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CLIFFTON
Other - Middle Name:
Other - Last Name:BONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 4399
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4399
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:2800 N VANCOUVER AVE STE 230
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227
Practice Address - Country:US
Practice Address - Phone:503-413-4340
Practice Address - Fax:503-413-4898
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24706207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227392Medicaid
OR227392Medicaid
ORH82035Medicare UPIN