1538302344 NPI number — KRYSTAL THOMAS SAMUEL DO

Table of content: KRYSTAL THOMAS SAMUEL DO (NPI 1538302344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538302344 NPI number — KRYSTAL THOMAS SAMUEL DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMUEL
Provider First Name:
KRYSTAL
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMAS
Provider Other First Name:
KRYSTAL
Provider Other Middle Name:
SARA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538302344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 SE STRATUS AVE
Provider Second Line Business Mailing Address:
SUITE 406
Provider Business Mailing Address City Name:
MCMINNVILLE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-435-1200
Provider Business Mailing Address Fax Number:
503-434-9572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 SE STRATUS AVE
Provider Second Line Business Practice Location Address:
SUITE 406
Provider Business Practice Location Address City Name:
MCMINNVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97128-6255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-435-1200
Provider Business Practice Location Address Fax Number:
503-274-5400
Provider Enumeration Date:
04/08/2009

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: 207R00000X , with the licence number:  DO172095 , 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: 500690584 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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