Organization
NORTHWEST DERMATOLOGY & LASER CLINIC PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BERT G TAVELLI MD (PRESIDENT)
(503) 295-2366
Entity
Organization
Contact information
Practice address
1130 NW 22ND AVE STE 330, PORTLAND, OR 97210-2970
(503) 295-2366
(503) 295-3065
Mailing address
PO BOX 23200, PORTLAND, OR 97281-3200
(503) 968-4620
(503) 968-2779
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
MD14681
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
028071
—
OR
01
—
DD5356
RAILROAD MEDICARE
OR
Enumeration date
06/29/2006
Last updated
06/01/2016
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