Basic Information
| Provider Information | |||||||||
| NPI: | 1104357714 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLBURN | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | JACOB | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 NE MULTNOMAH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10100 SE SUNNYSIDE RD | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970158970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2017 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD61204134 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD191309 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.