Provider Demographics
NPI:1740516434
Name:BENNETT, RACHEL JOHANNA (MD)
Entity type:Individual
Prefix:MS
First Name:RACHEL
Middle Name:JOHANNA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SW OAK ST
Mailing Address - Street 2:STE. 210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:12710 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3134
Practice Address - Country:US
Practice Address - Phone:503-988-3601
Practice Address - Fax:503-988-4167
Is Sole Proprietor?:No
Enumeration Date:2009-10-30
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD168554207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022959Medicaid
OR096511Medicaid
OR500690415Medicaid
ORR180505Medicare PIN
ORR180500Medicare PIN
ORR180502Medicare PIN
OR096511Medicaid
ORR0000WCJHTMedicare Oscar/Certification
OR500690415Medicaid
ORR180501Medicare PIN