Provider Demographics
NPI:1710129473
Name:THOMPSON, BREANNA SUMMERS (DO)
Entity type:Individual
Prefix:DR
First Name:BREANNA
Middle Name:SUMMERS
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:MARIE
Other - Last Name:SUMMERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16770 SW EDY RD STE 102
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9679
Practice Address - Country:US
Practice Address - Phone:503-216-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0049522208000000X
ORDO202589208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71333240Medicaid
COCOA108571Medicare PIN