Provider Demographics
NPI:1740200484
Name:MATHISEN, JEFFREY ROBERT (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ROBERT
Last Name:MATHISEN
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 1:1501 NE MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6051
Mailing Address - Country:US
Mailing Address - Phone:541-382-2811
Mailing Address - Fax:
Practice Address - Street 1:2200 NE NEFF RD STE 302
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4279
Practice Address - Country:US
Practice Address - Phone:541-706-6915
Practice Address - Fax:541-706-6733
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22909208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8277055Medicaid
OR287579Medicaid
WA8853807Medicare PIN
OR109677Medicare PIN
OR287579Medicaid
ORR181664Medicare PIN
OR020051593Medicare PIN