Provider Demographics
NPI:1265468615
Name:BONTA, MICHELLE D (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:BONTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:417 SW 117TH AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5924
Practice Address - Country:US
Practice Address - Phone:503-216-9400
Practice Address - Fax:503-216-9499
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25129207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00207043OtherRR MEDICARE - PH&S
OR233462Medicaid
ORR120369Medicare PIN
ORI13328Medicare UPIN