Basic Information
| Provider Information | |||||||||
| NPI: | 1609882281 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARRY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MAYNARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3303 SW BOND AVE | ||||||||
| Address2: | CH10U | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033461500 | ||||||||
| FaxNumber: | 5033461501 | ||||||||
| Practice Location | |||||||||
| Address1: | 3303 SW BOND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033461500 | ||||||||
| FaxNumber: | 5033461501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 03/13/2014 | ||||||||
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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 | 208800000X | MD07331 | OR | Y | Allopathic & Osteopathic Physicians | Urology | 204F00000X | MD07331 | OR | N | Allopathic & Osteopathic Physicians | Transplant Surgery |
ID Information
| ID | Type | State | Issuer | Description | 246389 | 05 | OR | MEDICAID |