Provider Demographics
NPI:1780661371
Name:WEBBER, BRUCE RANDOLPH (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:RANDOLPH
Last Name:WEBBER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:STE 532
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-488-2344
Practice Address - Fax:503-488-2360
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD 12636208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR154906Medicaid
OR154906Medicaid
ORR0000BHVHBMedicare ID - Type Unspecified
OR153513Medicare PIN