Provider Demographics
NPI:1710952494
Name:DEGENHARDT, JOHN H (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:DEGENHARDT
Suffix:
Gender:M
Credentials:DO
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 2040
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2040
Mailing Address - Country:US
Mailing Address - Phone:503-299-9906
Mailing Address - Fax:503-225-9002
Practice Address - Street 1:707 SW WASHINGTON ST
Practice Address - Street 2:SUITE 700
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3536
Practice Address - Country:US
Practice Address - Phone:503-299-9906
Practice Address - Fax:503-225-9002
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO16501207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD701ORMedicaid
CAXPY188986Medicaid
OR010251Medicaid
OR050056535OtherRR MEDICARE
WA1058940Medicaid
OR050056535OtherRR MEDICARE
E68800Medicare UPIN