Provider Demographics
NPI:1801095773
Name:LAFFERTY, BENJAMIN R (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:R
Last Name:LAFFERTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:534 PLEASANT VIEW WAY NW STE 300
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1789
Practice Address - Country:US
Practice Address - Phone:541-812-3323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV224052084P0804X
ORMD1770902084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500709165Medicaid
WV3810015793Medicaid