Provider Demographics
NPI:1962454280
Name:ROSENBAUM, JAMES TODD (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:TODD
Last Name:ROSENBAUM
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:PO BOX 4183
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208
Mailing Address - Country:US
Mailing Address - Phone:503-494-6107
Mailing Address - Fax:503-494-0470
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:L467AD
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-5023
Practice Address - Fax:503-494-6875
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14324207W00000X
OR14324207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130450Medicaid
180041844OtherRAILROAD MEDICARE
180041844OtherRAILROAD MEDICARE
C04194Medicare UPIN