Northwest Dermatology & Laser Clinic PC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

MD14681 Issued in OR

Legal business name

NORTHWEST DERMATOLOGY & LASER CLINIC PC

Practice address

1130 NW 22ND Ave Ste 330
Portland, OR 97210-2970

Phone

(503) 295-2366

Fax

(503) 295-3065

NPI assigned

Jun 29, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Bert G Tavelli, MD

Title

President

Phone

(503) 295-2366

Specialties & licenses 1

Addresses

Other identifiers 2

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151539200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1464739200000",
    "number": "1376571364",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 23200",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972813200",
            "telephone_number": "503-968-4620",
            "fax_number": "503-968-2779"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1130 NW 22ND AVE STE 330",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972102970",
            "telephone_number": "503-295-2366",
            "fax_number": "503-295-3065"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHWEST DERMATOLOGY & LASER CLINIC PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-29",
        "last_updated": "2016-06-01",
        "status": "A",
        "authorized_official_last_name": "TAVELLI",
        "authorized_official_first_name": "BERT",
        "authorized_official_middle_name": "G",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "503-295-2366",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": "OR",
            "license": "MD14681",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "DD5356",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "028071",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• All providers in Portland, OR
• Dermatology Physician in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 1, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.