Provider Demographics
NPI:1619061165
Name:BENDER, LEILA CLARK (MD)
Entity Type:Individual
Prefix:DR
First Name:LEILA
Middle Name:CLARK
Last Name:BENDER
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 1418
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1418
Mailing Address - Country:US
Mailing Address - Phone:805-286-3826
Mailing Address - Fax:805-221-6843
Practice Address - Street 1:938 NW KINGS BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-2505
Practice Address - Country:US
Practice Address - Phone:541-758-5047
Practice Address - Fax:541-758-3713
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD600279402085B0100X, 2085R0202X
ORMD2017002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0293142OtherL&I
OR500674855Medicaid
WA322487OtherL & I PROVIDER NUMBER
WA2017309Medicaid
WA319557OtherL & I PROVIDER NUMBER
WA322488OtherL & I PROVIDER NUMBER
WAP01247737Medicare PIN
WA319557OtherL & I PROVIDER NUMBER
WAP01247742Medicare PIN
WA322488OtherL & I PROVIDER NUMBER
WAG8920750Medicare PIN
WAG8920748Medicare PIN
WAG8920747Medicare PIN