Provider Demographics
NPI:1619977063
Name:BREDA, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:BREDA
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 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:503-413-5725
Mailing Address - Fax:503-413-5726
Practice Address - Street 1:1130 NW 22ND AVE
Practice Address - Street 2:SUITE #420
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2900
Practice Address - Country:US
Practice Address - Phone:503-413-5725
Practice Address - Fax:503-413-5726
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 18590208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR020042605OtherRAILROAD MEDICARE
OR061841Medicaid
WA1107531Medicaid
ORR105001Medicare PIN
F77085Medicare UPIN