Basic Information
| Provider Information | |||||||||
| NPI: | 1134171465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELEBER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | GORDON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3375 SW TERWILLIGER BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034946107 | ||||||||
| FaxNumber: | 5034940470 | ||||||||
| Practice Location | |||||||||
| Address1: | 3375 SW TERWILLIGER BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948386 | ||||||||
| FaxNumber: | 5034942218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 07/18/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD08302 | OR | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 180040496 | 01 | RAILROAD MEDICARE RRM | OTHER | 215111 | 05 | OR | MEDICAID |