Provider Demographics
NPI:1972559409
Name:HUSTED, BENNETH ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:BENNETH
Middle Name:ANN
Last Name:HUSTED
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5100 SW MACADAM AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6102
Mailing Address - Country:US
Mailing Address - Phone:971-202-5500
Mailing Address - Fax:971-202-5555
Practice Address - Street 1:5100 SW MACADAM AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-6102
Practice Address - Country:US
Practice Address - Phone:971-202-5500
Practice Address - Fax:971-202-5555
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO12837207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067593003OtherBLUE CROSS BLUE SHIELD #
OR232132Medicaid
OR232132Medicaid
OR067593003OtherBLUE CROSS BLUE SHIELD #