1174537047 NPI number — DIANE BOLDUC M.D.

Table of content: DIANE BOLDUC M.D. (NPI 1174537047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174537047 NPI number — DIANE BOLDUC M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLDUC
Provider First Name:
DIANE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174537047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
340 MEDICAL LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97470-1645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-464-5907
Provider Business Mailing Address Fax Number:
541-464-8481

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 MEDICAL LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97470-1645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-464-5907
Provider Business Practice Location Address Fax Number:
541-464-8481
Provider Enumeration Date:
07/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD23487 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 287185 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 840254000 . This is a "REGENCE BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: J103601 . This is a "PACIFIC SOURCE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 32945700000 . This is a "PROVIDENCE HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 608828900 . This is a "BLACK LUNG FEDERAL PROGRA" identifier . This identifiers is of the category "OTHER".