Basic Information
| Provider Information | |||||||||
| NPI: | 1619061165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENDER | ||||||||
| FirstName: | LEILA | ||||||||
| MiddleName: | CLARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1418 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973391418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052863826 | ||||||||
| FaxNumber: | 8052216843 | ||||||||
| Practice Location | |||||||||
| Address1: | 938 NW KINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973302505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417585047 | ||||||||
| FaxNumber: | 5417583713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | MD60027940 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | MD60027940 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD201700 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0293142 | 01 | WA | L&I | OTHER | 500674855 | 05 | OR | MEDICAID | 322487 | 01 | WA | L & I PROVIDER NUMBER | OTHER | 2017309 | 05 | WA | MEDICAID | 319557 | 01 | WA | L & I PROVIDER NUMBER | OTHER | 322488 | 01 | WA | L & I PROVIDER NUMBER | OTHER |