Provider Demographics
NPI:1790766764
Name:BILSTROM, DAVID E (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:E
Last Name:BILSTROM
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 1:9370 SW GREENBURG RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5442
Mailing Address - Country:US
Mailing Address - Phone:503-245-8060
Mailing Address - Fax:503-245-8104
Practice Address - Street 1:9370 SW GREENBURG RD
Practice Address - Street 2:SUITE A
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-5442
Practice Address - Country:US
Practice Address - Phone:503-245-8060
Practice Address - Fax:503-245-8104
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10617174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR004545000OtherREGENCE BX OF OREGON
OR01-7343Medicaid
OR030000141OtherRAILROAD MEDICARE
OR0000BHHMPOtherMEDICARE NUMBER
OR01-7343Medicaid