Provider Demographics
NPI:1922071513
Name:OPPENHEIMER, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:OPPENHEIMER
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 1:1130 NW 22ND AVE #220
Mailing Address - Street 2:LEGACY CLINIC NORTHWEST
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3025
Mailing Address - Country:US
Mailing Address - Phone:503-413-8988
Mailing Address - Fax:503-274-4815
Practice Address - Street 1:1130 NW 22ND AVE #220
Practice Address - Street 2:LEGACY CLINIC NORTHWEST
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3025
Practice Address - Country:US
Practice Address - Phone:503-413-8988
Practice Address - Fax:503-274-4815
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058549207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0571232Medicaid
143442OtherIHS
98999OtherBCWELLMARK 7TH ST
IL036058549002Medicaid
OR273137Medicaid
WA8497364Medicaid
98986OtherBCWELLMARK WEST
IL0182OtherJOHN DEERE
IA1571232Medicaid
IA0571232Medicaid
D13970Medicare UPIN
OR273137Medicaid