Basic Information
| Provider Information | |||||||||
| NPI: | 1609950849 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONG | ||||||||
| FirstName: | CLIFFTON | ||||||||
| MiddleName: | T.H. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BONG | ||||||||
| OtherFirstName: | CLIFFTON | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4399 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133900 | ||||||||
| FaxNumber: | 5034133710 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 N VANCOUVER AVE STE 230 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034134340 | ||||||||
| FaxNumber: | 5034134898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 08/14/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | MD24706 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 227392 | 05 | OR | MEDICAID |