Provider Demographics
NPI:1871686659
Name:TRAFFICANTE, BRIAN STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:STEPHEN
Last Name:TRAFFICANTE
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 1:800 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205
Mailing Address - Country:US
Mailing Address - Phone:503-221-0161
Mailing Address - Fax:503-274-1697
Practice Address - Street 1:800 SW 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205
Practice Address - Country:US
Practice Address - Phone:503-221-0161
Practice Address - Fax:503-274-1697
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13993207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR174789Medicaid
011WCHQRFMedicare ID - Type Unspecified
OR174789Medicaid