Provider Demographics
NPI:1619973856
Name:BIRK, BRUCE J (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:J
Last Name:BIRK
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 1:2231 SE ASH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1631
Mailing Address - Country:US
Mailing Address - Phone:503-736-1114
Mailing Address - Fax:
Practice Address - Street 1:2525 NW LOVEJOY ST
Practice Address - Street 2:STE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2863
Practice Address - Country:US
Practice Address - Phone:503-227-0671
Practice Address - Fax:503-227-0676
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21767208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134208Medicaid