Provider Demographics
NPI:1013918978
Name:TAVELLI, BERT G (MD)
Entity type:Individual
Prefix:
First Name:BERT
Middle Name:G
Last Name:TAVELLI
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 1:2525 NW LOVEJOY ST STE 400
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2865
Mailing Address - Country:US
Mailing Address - Phone:503-223-1933
Mailing Address - Fax:503-223-1947
Practice Address - Street 1:2525 NW LOVEJOY ST STE 400
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2865
Practice Address - Country:US
Practice Address - Phone:503-223-1933
Practice Address - Fax:503-223-1947
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 14681207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AT2285179OtherDEA
OR028071Medicaid
E84405Medicare UPIN
OR028071Medicaid