Basic Information
| Provider Information | |||||||||
| NPI: | 1255374740 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVITT | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11782 SW BARNES RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032145200 | ||||||||
| FaxNumber: | 5039066613 | ||||||||
| Practice Location | |||||||||
| Address1: | 11782 SW BARNES RD | ||||||||
| Address2: | 300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032145200 | ||||||||
| FaxNumber: | 5039066613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 23061 | OR | N | Other Service Providers | Specialist | 207Q00000X | MD23061 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207XX0004X | 23061 | OR | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | MD23061 | 01 | OR | OREGON MEDICAL LICENSE | OTHER | 229314 | 05 | OR | MEDICAID |